Components of the short nostril

Balancing the Anteroposterior Diameters of the Nostril Lengths in Cleft Rhinoplasty

BACKGROUND

Osteocartilaginous deformities in cleft rhinoplasties may be restored with numerous techniques. However, the anteroposterior (AP) diameter lengths of the nostrils may still be unequal and should also be addressed. A technique was designed to balance nostril AP diameter lengths and apical shapes.

MATERIALS AND METHODS

Balance between AP nostril diameters was accomplished by reduction of the AP diameter of the nostril at the non-cleft side by medial crural reduction and augmentation of the AP diameter of the nostril at the cleft side by three-parted mini-flap reconstruction at the soft triangle. The cleft-side AP diameter length was divided by the non-cleft-side AP diameter length of the same preoperative, per-operative and 1-year postoperative base view photographs of each patient, and "nostril balancing ratio" was obtained. The more this ratio was near to "one," the more the AP nostril diameters were equal.

RESULTS

Seventy-eight unilateral-cleft rhinoplasty were performed between January/2019 and May/2022. Forty-two of them required nostril AP diameter equalization. Twenty-nine patients were female, thirteen were male. Thirty-three of them were operated for a primary cleft rhinoplasty. Nine of them for secondary cleft rhinoplasty. Mean age was 28 years (22-39 years). Mean follow-up was 25 months (6-40 months). The preoperative, per-operative and postoperative mean "nostril balancing ratios" were 0.714 (0.621-0.813), 0.743 (0.721-0.752) and 0.971 (0.943-0.976), respectively.

CONCLUSION

Balancing AP diameter symmetry with MCO at the non-cleft side and three-parted mini skin flap reconstruction at the cleft side may provide the satisfactory results. Three mini-flaps at the soft triangle may remold the nostril apex in an oval shape, which may result in a better shape symmetry.

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 .

A comprehensive analysis of the correction of alar retraction in rhinoplasty: A systematic review

BACKGROUND

Alar retraction, as a type of alar deformity, seriously affects the esthetic perception of the nose in patients. Despite the rapid development of rhinoplasty in recent years, the treatment of alar retraction is still a challenge work in plastic surgery. This systematic review highlights the etiology, treatment, and prevention of alar retraction to further guide practitioners.

METHODS

A systematic review was conducted from 1975 to 2020 through PubMed, Embase, Web of Science, and Cochrane database with the key words "alar retraction" and "rhinoplasty" or "Rhinoplasties" to investigate the surgical treatment of alar retraction. The inclusion and exclusion criteria were set to screen the literature.

RESULTS

A total of 163 literatures were obtained through database retrieval. After removing the duplicate literature, reading the title and abstract, and reviewing the full text finally, 34 articles were included in the final study. Most of the articles have summarized the surgical methods to correct alar retraction by retrospective study.

CONCLUSIONS

Alar retraction should be analyzed from the etiology, pathogenesis, and treatment. The diversity of surgical methods provides more options for the clinic. However, the plastic surgeons need to develop sharp analytical skills, improve clinical operational capability, and look for appropriate methods to achieve in good result.

Application of Autologous Cartilage Transplantation in the Reconstruction of Congenital Nasal Soft Triangle Deformities in Asians

BACKGROUND

Nasal soft triangle is one of the areas usually left unattended in most rhinoplasties, whereas its unique anatomy puts it at great risk of deformities. Its appearance is critical to the natural contour of the nasal tip lobule. The purpose of this study was to evaluate the outcome of autologous cartilage transplantation in treating congenital nasal soft triangle deformities in Asians.

METHODS

From January 2016 to January 2018, 32 patients underwent the procedure, in which costal cartilage, septal cartilage, or conchal cartilage was taken. All cases were operated upon using the external rhinoplasty approach. The cartilage was carved into battens as the lateral and intermediate crura grafts to reconstruct the dome of alar cartilage and treat the soft triangle deformities. The costal cartilage or septal cartilage was used as a columella strut. At the same time, a prosthesis or costal cartilage scaffold was placed onto the nasal dorsum, and finally the fascia was placed on the tip of the nose to relieve tension. The changes of the angle between the intermediate and lateral crura of the alar cartilage before and after cartilage graft and the difference between the greatest distance from the long axis of the nostrils to the alar rim before and after surgery were statistically analyzed. In addition, we compared the preoperative and postoperative nasal contour and evaluated the outcome of soft tissue triangle deformities and asymmetry correction and the whole procedure.

RESULTS

The angle between the lateral and medial crura of the 32 patients decreased from 51.5 ± 10.9 degrees preoperatively to 37.2 ± 5.9 degrees at completion of the nasal dome reconstruction (P < 0.05). The maximum distance from the long axis of the nostrils to the alar rim was 3.3 ± 0.6 mm preoperatively and 1.9 ± 0.7 mm postoperatively (P < 0.05). The patients were followed up for 6 to 18 months, and the noses were with natural contour and tactile impression and without any serious complications. The degree of satisfaction was 87.5%.

CONCLUSIONS

The application of autologous cartilage is an ideal choice to treat soft triangle deformities, which can result in significant improvement of the nasal contour and high degree of satisfaction postoperatively.

Economizing the Septal Cartilage for Grafts During Rhinoplasty, 40 Years' Experience

BACKGROUND

During rhinoplasty, it is typically necessary to use cartilage to shape and support the final nasal construct to provide both form and function to the nose (Tanna et al. in Plast Reconstr Surg 141(1):137e-151e, 2018; Guyuron in Plast Reconstr Surg 105(6):2257-2259, 2000; Kim et al. in Ann Plast Surg 65(6):519-523, 2010). The septal cartilage is the ideal graft both for its ease of access and quality of cartilage. However, this graft is a limited resource, and economy of its use is important as to negate the need to harvest cartilage from the ear or rib.

THE PURPOSE

1. To share the senior author's 40 years' experience with the economy of septal cartilage. 2. To identify the areas of the septal cartilage most suitable for a particular graft. 3. To discuss the common grafts that are used in rhinoplasty. 4. To identify when other sources of cartilage are needed and where to best use those grafts. 5. To present option for preservation of the leftover septal cartilage.

CONCLUSION

Overall consideration should focus on the size, thickness, and curvature of the graft contemplating the structural and functional needs of the rhinoplasty maneuvers.

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 .

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.

Suture techniques and cartilage grafts in nasal tip surgery: An algorithm in primary and secondary rhinoplasty

OBJECTIVE

In most primary and secondary rhinoplasties, the adjustment of the nasal tip in terms of position, projection, and configuration is mandatory. Usually, this is one of the most challenging parts of the operation. The aim of this study was to present a step-by-step algorithm that evaluates popular techniques for a predictable outcome.

PATIENTS AND METHODS

A single-surgeon retrospective review of primary and secondary rhinoplasty patients was undertaken for nasal tip refinement. An overview of popular and clinically relevant suture techniques and cartilage grafts is provided, in particular, concerning the position, projection, and rotation. On the basis of clinical examples, we will present different indications, the latest operative treatment options, and long-term results.

RESULTS

Between 2013 and 2018, we devised an algorithm based on 322 patients. Ninety patients (28%) were admitted for primary rhinoplasties and 232 patients for secondary rhinoplasties (72%). Our patients reported overall high satisfaction rates, and no further revisions were required.

CONCLUSIONS

Preoperative analyses and the knowledge of different suture techniques and cartilage grafts for nasal tip surgery are crucial factors for a successful postoperative outcome.

Middle Eastern Rhinoplasty: Update

Middle Eastern rhinoplasty requires especially precise preoperative planning to achieve a successful result. Among all aesthetic surgery procedures, there is a higher demand for rhinoplasty among Middle Eastern cultures. The key is to maintain the ethnicity of the patients while meeting their goals. In this brief overview, common features in Middle Eastern patients and Middle Eastern rhinoplasty techniques in men and women are highlighted.

Nasal Tip Grafts

OBJECTIVES

The nasal tip is the most prominent part of the nose. The aim of this paper is to review nasal tip grafts with detailed explanation and figures.

METHODS

The authors searched PubMed, Google, Google Scholar, and Proquest Central database of the Kirikkale University. Search was performed with the key words of "nasal," "tip," "graft." The indications and grafting techniques were presented.

RESULTS

The external shape of the nasal tip is determined by the curves and contours of the lower lateral cartilages and their interactions with the surrounding tissues. Normative data exist regarding the ideal shape and shadowing of the nasal tip. The mainly used tip grafts in rhinoplasty are "Floating graft (Goldman) ," "Tip Onlay Graft," "Columellar Strut Graft," "Caudal Septal Extension Graft," "Shield Graft," "Alar batten onlay graft," "Lateral Crural Strut Grafts," "Alar rim grafts."

CONCLUSION

When tip sutures are not enough, cartilage tip grafts offer a versitile and effective way to change the nasal tip. While there has been a vast array of grafting techniques described, this paper reviewed many of the most popular and useful grafts in modern use.

Preventing Soft-Tissue Triangle Collapse in Modern Rhinoplasty

The unique anatomy of the soft-tissue triangle makes it prone to notching in primary, secondary, and reconstructive rhinoplasty. Understanding the anatomy of the region is critical to appropriate treatment. This article is meant to further clarify the anatomy of the soft-tissue triangle and to present the senior author's (R.J.R.) approach to proactive correction and prevention of soft-tissue triangle notching through five key steps: (1) precise dissection and incision placement, (2) providing internal support with cartilage grafting if needed, (3) closure of dead space, (4) avoiding undue tension during closure, and (5) providing external support postoperatively.

The Importance of Soft Triangle in Rhinoplasty

The soft triangle is a basic, yet delicate and vulnerable, subunit of the nose that is under-rated both academically and surgically. The soft triangle is located at the apex of the nostril, at the point where the dermis is in direct contact with dermis that contains no intervening subcutaneous tissue and it may be unintentionally harmed during rhinoplasty.The authors suggest using a modified incision and closure and filling with significantly or severely crushed cartilage to prevent notching and to provide support for the soft triangle. The more the authors understand the nature of the soft triangle, the more they will be able to obtain superior surgical results in the nasal tip area.

Reshaping of the Broad and Bulbous Nasal Tip

This article presents a contemporary overview of tip suturing and tip structural grafting techniques used to refine the wide nasal tip. Previous reductive techniques have proved to produce unnatural results over time. It is imperative to correctly evaluate the nose and assess all possible pitfalls during the preoperative period before outlining a surgical plan. Intraoperatively, an algorithmic approach helps obtain a reproducible and refined yet properly narrowed domal tip region with graceful contours that extend laterally to the alar lobule with proper shadowing.

Anatomical Study of the Lateral Crural Strut Graft in Rhinoplasty and Its Clinical Application

BACKGROUND

Lateral crural strut graft has been used in rhinoplasty to correct deformities such as bulbous nasal tip, lateral crus malposition, alar retraction, collapsed external valve, lateral crus concavity, and alar deformity after domal suture. Despite its widespread use, the lateral crural strut graft has not been the subject of studies that show its benefits objectively and statistically.

OBJECTIVES

To assess nasal anatomical variations in cadavers that underwent rhinoplasty using the lateral crural strut graft, considering the clinical applications of this graft.

METHODS

The study was conducted with 16 human cadavers that underwent rhinoplasty with lateral crural strut graft. The variables were basilar nasal width, interalar width, columella-nasal tip height, nostril's width, and length and width of the graft. Measurements were taken with a digital caliper before and after rhinoplasty, and nostril cross-sectional area was measured with a computer program. All measurements were submitted to statistical analysis.

RESULTS

Most of the cadavers were young, male, and black. Variables values were increased, but only basilar nasal width, columella-nasal tip height, and nostril cross-sectional area showed statistically significant differences (P < .05), leading to changes in the alar base, the nasal tip projection and the external nasal valve.

CONCLUSIONS

Lateral crural strut graft improves external nasal valve and increases nasal tip projection and basilar nasal width.

Assessment of nasal base morphology using new proportion indices in Chinese

Objective

The aim of this study was to measure the soft tissue of the external nasal base in Han Chinese women and identify indices with which to simplify morphological assessment.

Methods

This study involved 155 Han women in China. The control group comprised 101 women, and the surgical group comprised 54 women. Using measurements and analytical software, we measured the nasal base on photographs in the two groups. The nasal base was also measured preoperatively and postoperatively in the surgical group. Results from the two groups were compared with a t test.

Results

The proportion index of the nasal tip triangle (upper nasal base) was c-prn/a = 0.33 ± 0.05 ≈ 1:3. The proportion index of the nostril trapezoidal (lower nasal base) was c-sn/all-alr = 0.25 ± 0.04 ≈ 1:4. The proportion indices of the nasal tip triangle and the nostril trapezoidal were larger in the postoperative surgical group than in the control group. Therefore, the nasal base morphology became stereoscopic through surgical correction.

Conclusion

The current study provides a credible and objective reference for cosmetic nasal surgery. The proportion indices related to the nasal base can be used to intuitively and vividly ascertain the nasal base morphology.

Level of evidence

III.

Nasal Analysis and Anatomy: Anthropometric Proportional Assessment in Asians-Aesthetic Balance from Forehead to Chin, Part I

Asian rhinoplasty patients can be analyzed by the nose's component structures and their relationship to one another. A comprehensive understanding of the underlying anatomical structure including bone, cartilage, and soft tissue contributes to better preoperative planning. To achieve an optimal postoperative result, a thorough preoperative analysis utilizing standardized measurements is essential. Knowledge of the Asian nose facilitates the use of an algorithmic approach to Asian rhinoplasty that increases surgical predictability.

The Soft Triangle: An Often Neglected Area in Rhinoplasty

BACKGROUND

This study aims to focus on one of the lesser mentioned topics in discussions of aesthetic nose operations, the soft triangle. In addition to outlining the characteristics of the area, the various complications specific to the soft triangle are discussed along with methods and techniques utilized by the authors to avoid such complications.

METHODS

One hundred twenty-seven of 841 (15 %) patients who were assessed both preoperatively and intraoperatively for the presence of an anatomical issue of the soft triangle were included in the study. Patients were divided into three groups according to their anatomical features that were identified intraoperatively. The preoperative and postoperative photographs of all patients were compared to assess the effects of the respective soft triangle grafts on both nostril length and the nostril/lobule harmony.

RESULTS

The average follow-up time of the patients was 27 months (6-60). Postoperative notching (of various degrees) was found in six (6/127) total patients: one (1/31) patient in the first group, two (2/24) patients in the second group, and three (3/72) patients in the third group.

CONCLUSION

Neglecting the soft triangle area might yield grim results in terms of cosmetic and functional aspects. To avoid these problems, incisions should be planned purposefully, and patients who have anatomically weak support should be identified so that additional precautions should be taken for these cases.

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 .

Surgical considerations in secondary rhinoplasty for effective correction of an asymmetric nostril

PURPOSE

Asymmetric nostrils that develop after rhinoplasty may result in nasal tip deformity and result in patient dissatisfaction. No systemic study on methods for the correction of transformed nostrils has been reported. In the current study, asymmetric nostrils were classified according to the degree of asymmetry and the authors' experiences on the correction of nostril deformities are described.

METHODS

Thirty-nine patients who experienced asymmetric nostrils after primary rhinoplasty were selected for the current study. Nostril asymmetry was classified as types 1 to 3. All patients underwent secondary rhinoplasty, and 3-dimensional total alar cartilage dissection and reposition were performed on most patients. Patient satisfaction was assessed using a 5-level index.

RESULTS

Of the 39 patients, 10 were classified as having asymmetry type 1; 13, asymmetry type 2; and 16, asymmetry type 3. The mean follow-up period after the secondary rhinoplasty was 17 months. Of the 39 patients, a total of 34 showed improvement in asymmetry after the surgery. Of the remaining 5 patients, 3 patients showed incomplete correction and 2 patients showed deteriorated asymmetry. In the patient satisfaction survey, 31 of the 39 patients answered "somewhat satisfied" or "very satisfied."

CONCLUSIONS

Before the correction of asymmetric nostrils that developed after primary rhinoplasty, the cause of the asymmetry should be analyzed and appropriate procedures should be selected. Three-dimensional total alar cartilage dissection and reposition are both useful methods for the correction of alar cartilage asymmetry.

Contemporary techniques for effective nasal lengthening

The short nose deformity is a complex entity with diverse causes and variable characteristics. This article divides shortening into anterior and pan-nose shortening as well as mild, moderate, or severe. Mild anterior shortening can be corrected with shield grafting, whereas moderate to severe shortening can be corrected using septal extension grafts, composite grafts, or the tongue-and-groove technique. Ancillary technical considerations are reviewed. General principles of patient assessment and rhinoplasty execution are discussed. Surgical cases are presented, and pertinent aspects of preoperative planning, surgical technique, and perioperative care are discussed.

Dynamics of the alar rim graft

BACKGROUND

The purpose of this study was to review the dynamics and frequency of the use of the alar rim graft.

METHODS

The recorded intraoperative information for the purpose of rhinoplasty research was reviewed to investigate the frequency of the use of alar rim grafts. Intraoperative observations were also made while inserting the alar rim graft to identify the changes that occur in the structures that could be influenced by placement of this graft. The data were tabulated in an Excel file and analyzed.

RESULTS

Of the 1427 patients who underwent nose reconstruction or rhinoplasty in this study, 565 (39.56 percent) received alar rim grafts. This included 73 primary nose reconstructions, 20 secondary nose reconstructions, two revision nose reconstructions, 304 primary rhinoplasties, 107 secondary rhinoplasties, 43 revision operations following primary rhinoplasties, and seven revision operations following secondary rhinoplasties. However, when 100 more recent consecutive cases were reviewed, 88 percent of primary rhinoplasty patients and 67 percent of secondary rhinoplasty patients received alar rim grafts. The observed dynamic changes after insertion of each graft included (1) correction of the concavity of the ala, (2) caudal advancement of the alar rim, (3) elongation of nostril, and (4) widening of the nostril.

CONCLUSIONS

The majority of patients who undergo rhinoplasty would benefit from the alar rim graft, and this study demonstrates a steady increase in its use. Placement of an alar rim graft results in elongation of the short nostril, correction of the alar concavity, widening of the nostril, and slight caudal transposition of the alar rim.

Grafting the alar rim: application as anatomical graft

BACKGROUND

Alar rim contour and alar rim grafts have become essential components of rhinoplasty. Ideally, grafts of the nose should be anatomical in shape. So doing might make grafts of the alar rim more robust. The authors considered doing that by applying the graft as a continuous extension of the lateral crus.

METHODS

Twelve patients (two men and 10 women) constituted the study group (seven primary and five secondary cases). Of those, there were five concave rims, two concave rims with rim retraction, two boxy tips, and three cephalically oriented lateral crura. Surgical technique included the following: (1) an open approach was used; (2) a marginal incision that ignored the caudal margin of the lateral crus (the incision went straight posteriorly to a point 5 to 6 mm from the rim margin) was used; (3) a triangular graft was made to cover the exposed vestibular skin; (4) it was secured end to end to the caudal border of the lateral crus; and (5) the poster end was allowed to sit in a small subcutaneous pocket.

RESULTS

Follow-up was 11 to 19 months. All 12 patients exhibited good rims as judged by a blinded panel. Rim retraction was not fully corrected in one patient, but no further treatment was required. One patient did require a secondary small rim graft for residual rim concavity.

CONCLUSIONS

The concept of grafting the alar rim is strongly supported by the authors' results. The modifications the authors applied by designing the graft to be anatomical in shape has been a technical help.

Reshaping the medial nostril and columellar base: five-step medial crural footplate approximation

Achieving ideal shape and position of the medial nostril and columellar base is a crucial component of successful rhinoplasty. The lateral border of the basal columella should exhibit slight concavity and a relatively smooth contour. Both nasal aesthetics and functionality may be compromised if such a result is not obtained. Herein, a reproducible technique is described which allows for treatment of this region.

Cleft nasal deformity and rhinoplasty

The cleft nasal deformity is a complex challenge in plastic surgery involving the skin, cartilage, mucosa, and skeletal platform. Ever since Blair and Brown first described the intricacies of the cleft pathology in 1931, the appropriate approach has been extensively debated in the literature with respect to timing, technique, and extent of surgical intervention. In this article, the authors review the literature and summarize the various modalities for achieving a successful rhinoplasty in the patient with a cleft nasal deformity.

Modified technique to increase nostril cross-sectional area after using rib and septal cartilage graft over alar nasal cartilages

PURPOSE

Describe a modified technique to increase nostril cross-sectional area using rib and septal cartilage graft over alar nasal cartilages.

METHODS

A modified surgical technique was used to obtain, carve and insert cartilage grafts over alar nasal cartilages. This study used standardized pictures and measured 90 cadaveric nostril cross-sectional area using Autocad(®); 30 were taken before any procedure and 60 were taken after grafts over lateral crura (30 using costal cartilage and 30 using septal cartilage). Statistical analysis were assessed using a model for repeated measures and ANOVA (Analysis of Variance) for the variable "area".

RESULTS

There's statistical evidence that rib cartilage graft is more effective than septal cartilage graft. The mean area after the insertion of septal cartilage graft is smaller than the mean area under rib graft treatment (no confidence interval for mean difference contains the zero value and all P-values are below the significance level of 5%).

CONCLUSIONS

The technique presented is applicable to increase nostril cross section area in cadavers. This modified technique revealed to enhance more nostril cross section area with costal cartilage graft over lateral crura rather than by septal graft.

Ethnic rhinoplasty

This article examines the surgical techniques of rhinoplasty in relation to aesthetic considerations of various ethnic groups. Rhinoplasty in general is challenging, particularly in the ethnic population. When considering rhinoplasty in ethnic patients one must determine their aesthetic goals, which in many cases might deviate from the so-called norm of the "North European nose." An experienced rhinoplastic surgeon should be able to navigate his or her way through the nuances of the various ethnic subsets. Keeping this in mind and following the established tenets in rhinoplasty, one can expect a pleasing and congruous nose without radically violating ethnicity.

'Universal retraction suture' for the overprojecting nasal tip

Achieving a proper nasal tip projection is a crucial element of a successful rhinoplasty. A large number of correction methods and manoeuvres have been proposed in the medical literature as solutions for the prominent nasal tip, thus complicating the surgeon's strife to choose the ideal plan of action. In the present article, a single straight-forward technique, christened the 'universal retraction suture', is suggested to tackle the overprojecting tip in a simplified, controlled and efficient fashion.

Ethnic rhinoplasty

As the United States becomes more racially and ethnically diverse, the number of non-Caucasian patients seeking rhinoplasty is increasing. The non-Caucasian, or ethnic, rhinoplasty patient can be a surgical challenge due to the significant anatomic variability from the standard European nose as well as variability within each ethnicity. Becoming familiar with the common anatomic differences as well as the aesthetic goals in the ethnic rhinoplasty patient will assist the surgeon in attaining consistent, ethnically congruent, and aesthetically pleasing results.

Alar base disharmonies

The nasal base is often overlooked during the initial planning of rhinoplasty. Poor surgical planning or improper correction of alar base disharmonies can be irreversible and can have significant functional consequences. This article simplifies the recognition of common alar base disharmonies. The classification system is intended to facilitate choosing the best surgical technique to correct the alar base flaws.

Current status of grafts and implants in rhinoplasty: part I. Autologous grafts

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the challenges in restoring volume and structural integrity in rhinoplasty. 2. Identify the appropriate uses of various autografts in aesthetic and reconstructive rhinoplasty (septal cartilage, auricular cartilage, costal cartilage, calvarial and nasal bone, and olecranon process of the ulna). 3. Identify the advantages and disadvantages of each of these autografts.

SUMMARY

This review specifically addresses the use of autologous grafts in rhinoplasty. Autologous materials remain the preferred graft material for use in rhinoplasty because of their high biocompatibility and low risk of infection and extrusion. However, these advantages should be counterbalanced with the concerns of donor-site morbidity, graft availability, and graft resorption.

Rhinoplasty for Middle Eastern noses

BACKGROUND

Rhinoplasty remains one of the most challenging operations, as exemplified in the Middle Eastern patient. The ill-defined, droopy tip, wide and high dorsum, and thick skin envelope mandate meticulous attention to preoperative evaluation and efficacious yet safe surgical maneuvers. The authors provide a systematic approach to evaluation and improvement of surgical outcomes in this patient population.

METHODS

A retrospective, 3-year review identified patients of Middle Eastern heritage who underwent primary rhinoplasty and those who did not but had nasal photographs. Photographs and operative records (when applicable) were reviewed. Specific nasal characteristics, component-directed surgical techniques, and aesthetic outcomes were delineated.

RESULTS

The Middle Eastern nose has a combination of specific nasal traits, with some variability, including thick/sebaceous skin (excess fibrofatty tissue), high/wide dorsum with cartilaginous and bony humps, ill-defined nasal tip, weak/thin lateral crura relative to the skin envelope, nostril-tip imbalance, acute nasolabial and columellar-labial angles, and a droopy/hyperdynamic nasal tip. An aggressive yet nondestructive surgical approach to address the nasal imbalance often requires soft-tissue debulking, significant cartilaginous framework modification (with augmentation/strengthening), tip refinement/rotation/projection, low osteotomies, and depressor septi nasi muscle treatment. The most common postoperative defects were related to soft-tissue scarring, thickened skin envelope, dorsum irregularities, and prolonged edema in the supratip/tip region.

CONCLUSIONS

It is critical to improve the strength of the cartilaginous framework with respect to the thick, noncontractile skin/soft-tissue envelope, particularly when moderate to large dorsal reduction is required. A multitude of surgical maneuvers are often necessary to address all the salient characteristics of the Middle Eastern nose and to produce the desired aesthetic result.

Tip shaping in primary rhinoplasty: an algorithmic approach

BACKGROUND

Underprojection and lack of tip definition often coexist. Techniques that improve both nasal tip refinement and projection are closely interrelated, and an algorithmic approach can be developed to improve the predictability of the dynamic changes that occur. Use of nondestructive and nonpalpable techniques that enhance nasal tip shape are emphasized.

METHODS

A retrospective review of primary rhinoplasty patients was undertaken to delineate the precise role of preoperative analysis, intraoperative evaluation, and execution of specific surgical techniques in creating nasal tip refinement and projection. Specific case studies are used to demonstrate the efficacy and predictability of these maneuvers.

RESULTS

Successful tip refinement and projection depends on (1) proper preoperative analysis of the deformity; (2) a fundamental understanding of the intricate and dynamic relationships between tip-supporting structures that contribute to nasal tip shape and projection; and (3) execution of the operative plan using controlled, nondestructive, and predictable surgical techniques.

CONCLUSIONS

A simplified algorithmic approach to creating aesthetic nasal tip shape and projection in primary rhinoplasty has been established to aid the rhinoplasty surgeon in reducing the inherent unpredictability of combined techniques and improving long-term aesthetic outcomes.

The intercartilaginous graft for actual and potential alar retraction

BACKGROUND

Alar retraction deformities occasionally require significant soft-tissue release and relatively large cartilage grafts. In addition, correction of the short nose by only lengthening the septum can result in potential postoperative alar retraction. Consequently, both types of cases, true and potential alar retraction (in short noses), would benefit from a technique that lengthens the sidewall of the nose.

METHODS

The intercartilaginous graft technique is a modification of the lateral crural strut graft technique. An intercartilaginous graft is inserted between the upper lateral cartilage and what remains of the lateral crus (lateral crus element). The technique emphasizes maximum soft-tissue release to insert a cartilaginous graft that spans the gap between the upper lateral cartilage and the lateral crus element. The graft is inserted under slight tension to maintain maximum lengthening of the sidewall of the nose.

RESULTS

Thirteen patients had intercartilaginous grafts placed. Seven patients had actual alar retraction and six patients had short noses with potential alar retraction. There was no postoperative alar retraction in 10 patients. Two patients with actual alar retraction were not completely corrected, and one required surgical revision. One patient with a short nose exhibited postoperative alar retraction, but it was not significant enough to warrant reoperation.

CONCLUSIONS

The intercartilaginous graft technique, a modification of the lateral crural strut graft technique, corrects moderate to severe alar retraction and prevents alar retraction after lengthening of very short noses. Its success depends on substantial soft-tissue release and insertion of a maximal sized graft between the upper lateral cartilage and the lateral crus element under slight tension.

MOC-PS(SM) CME article: late cleft lip nasal deformity

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the components of unilateral and bilateral secondary or delayed cleft lip nasal deformity. 2. Design and execute the surgical correction more logically. 3. Minimize the risks and better manage complications and suboptimal outcomes.

SUMMARY

Rhinoplasty remains one of the most challenging plastic surgery procedures, and patients with a cleft lip nose deformity pose an even greater challenge. The biggest enigmas are achievement of caudal nose congruity and creation of symmetric nostrils. This article reviews the factors to consider when assessing a patient for correction of secondary cleft lip nasal abnormalities and the surgical techniques available to correct the deformities. Some of the components of the unilateral cleft lip nose deformity include asymmetric tip, short columella, long lateral crus, flat nostril, wide alar base, caudal positioning of the nostril floor on the cleft side, and a short and deviated columella. The common features of bilateral cleft lip nose deformity include short columella, underprojected tip, flat alae, and wide and often asymmetric and horizontal nostrils. While an endonasal approach can improve these noses, the most success is attained through an open technique. Systematic reorientation of distorted nasal architecture, especially the lower lateral cartilages, and creation of a balanced platform for the lower lateral cartilages constitute some of the cardinal principles for correcting the cleft lip nose deformities. Potential complications and ways to minimize them are discussed.