The intercartilaginous graft for actual and potential alar retraction

Application of scalp graft in the correction of severe alar retraction

BACKGROUND

Alar retraction is characterized by excessive nostril exposure and presents a significant challenge in rhinoplasty, particularly in cases of severe alar retraction. This study aimed to introduce a novel treatment approach for severe alar retraction using a scalp graft.

METHODS

A retrospective study was conducted on 18 patients with severe alar retraction, defined by the extent of nostril exposure in the frontal view relative to the facial surface, who underwent revision rhinoplasty between May 2022 and May 2023. Scalp grafts were used to address severe alar retraction. Postoperative outcomes were assessed using the rhinoplasty outcomes evaluation (ROE) scale and visual analog scale (VAS) for patient satisfaction.

RESULTS

Postoperative assessments revealed significant improvements in the ratio of the distance from the nasal base midline to the alar edge in the frontal view relative to the corresponding distance in the basal view (P < 0.05); significant improvements were notes in ROE and VAS scores as well (P < 0.05). All patients reported satisfaction with the overall aesthetic outcomes of the surgery, and no significant complications were observed during the follow-up period.

CONCLUSION

The use of scalp grafts correcting severe alar retraction is a feasible and innovative approach. Key advantages include a skin tone that closely matches that of the nasal vestibule, concealed scar, and excellent graft survivability.

External Z-plasty Technique for Correction of Alar Retraction in Asian Patients

BACKGROUND

Current strategies for correcting alar retraction mainly include cartilage grafting and composite grafting, which are relatively complicated and may produce injury to the donor site. Herein, we introduce a simple and effective external Z-plasty technique for correcting alar retraction in Asian patients with poor skin malleability.

METHODS

Twenty-three patients were presented with alar retraction and poor skin malleability, and they were very concerned about the shape of the nose. These patients undergoing external Z-plasty surgery were analyzed retrospectively. In this surgery, no grafts were needed, and the location of the Z-plasty was according to the highest point of the retracted alar rim. We reviewed the clinical medical notes and photographs. During the postoperative follow-up period, patients' reported satisfaction with aesthetic outcome were also evaluated.

RESULTS

The alar retraction of all the patients was successfully corrected. The postoperative mean follow-up period was 8 months (range: 5-28 mo). No incidents of flap loss, recurrence of alar retraction, or nasal obstruction were observed during postoperative follow-up. Within postoperative 3-8 weeks, minor red scarring was visible at the operative incisions in most patients. However, these scars turned unobvious after postoperative 6 months. There were 15 cases (15/23) being very satisfied with the aesthetic outcome of this procedure. Seven patients (7/23) were satisfied with the effect and the invisible scar of this operation. Only one patient was dissatisfied with the scar, but she was satisfied with the correction effect of the retraction.

CONCLUSION

This external Z-plasty technique can be an alternative method for correction of alar retraction with no need of cartilage grafting, and the scar can be unobvious with fine surgical suture. However, the indications should be limited in patients with severe alar retraction and poor skin malleability, who should not particularly care about the scars.

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.

Alar Rim Triangular Flap for Congenital Nasal Cleft Repair in Pediatric Patients

BACKGROUND

According to Tessier classification, number 1 and number 2 craniofacial clefts involve the nasal ala. Congenital nasal cleft is not common and is difficult for reconstruction. Notches in the medial one-third of either nasal ala are typical manifestations in these patients. Herein, we introduce a alar rim triangular flap, which is indeed a local flap, for the treatment of isolated nasal cleft due to congenital deformities in pediatric patients.

METHODS

The authors conducted a retrospective cohort study including 10 consecutive pediatric patients undergoing this surgery. This alar rim triangular flap including 2 triangles was existing nasal tissue near the cleft. The alar rim defect was covered through local tissue re-arrangement. The authors reviewed the photographs and clinical medical notes of these patients carefully. Self-reported satisfactions of patients (or children's parents) with the scar morphology and correction effect of this procedure were evaluated as well at postoperative every follow-up.

RESULTS

All the cases were followed up regularly, and the average follow-up time was 22 months (ranged from 13-38 months). All the nasal clefts were reconstructed successfully. The alar rim triangular flap survived with no flap loss. The wound created by this procedure healed primarily. No alar retraction, nasal obstruction or step-off deformities were observed during postoperative follow-up. There were no patients unsatisfied with the outcome of the scar morphology and correction effect of this operation.

CONCLUSIONS

The newly designed alar rim triangular flap in this study can be an alternative treatment for correcting isolated congenital nasal cleft with optimal clinical outcome.

LEVEL OF EVIDENCE

Level 4.

Caudal Extension Graft of the Lower Lateral Cartilage: Technique and Aesthetic and Functional Results

Here we describe a new technique to deal with alar retraction, a highly undesirable imperfection of the nose. The procedure involves placing a caudal extension graft below the vestibular portion of the lower lateral cartilage (LLC) after its detachment from the vestibular skin. The graft is fixed to the cartilage and, subsequently, to the vestibular tissue. The present retrospective study included 20 patients, 11 females and 9 males, with a mean age of 28.90 years. Follow-up ranged from 1 to 18 months. Surgery improved alar notching to a smoother dome shape and nostril exposure was reduced in every patient. The caudal extension graft of the LLC contributed to rise in overall patient satisfaction, as revealed by the postoperative increase of the Rhinoplasty Outcomes Evaluation (ROE) mean score from 40.0 to 79.17 (p < 0.0001). It also contributed to and improved functional outcomes, as indicated by the decrease of the Nasal Obstruction Symptom Evaluation (NOSE) mean score from 52.75 to 13.25 (p = 0.0001). Sex did not affect the mean ROE and NOSE scores. Thus, increased patient satisfaction measured by the ROE is present in both sexes and at both age groups but it is better detected in the first year after surgery. Functional improvements analyzed with NOSE are best detected in patients aged ≥ 30 years and in follow-ups of 11 months. The caudal extension graft of the LLC technique described herein effectively and safely corrects alar retraction and the collapse of the nasal valve while filling the soft triangle.

Defining the Histologic Support Structures of the Nasal Ala and Soft Triangle: Toward Understanding the Cause of Iatrogenic Alar Retraction

BACKGROUND

As rhinoplasty techniques have evolved to more extensive dissections, the incidence of iatrogenic deformities, such as alar rim retraction, has risen. Its mechanism is presently unknown. This study examined the microscopic anatomy of the nasal ala to define architectural support elements at the histologic level to determine why rhinoplasty dissection creates such deformities.

METHODS

Eight cadaveric noses were harvested and sectioned through the soft triangle and ala. Various tissue stains were performed. Slides were examined using light microscopy. Anatomical features pertaining to cartilage, skin, mucosa, elastic fibers, and muscle were documented.

RESULTS

Four male and four female noses were sectioned. The median cadaver age was 64 years (range, 47 to 83 years). On Elastica van Gieson stain, distinct elastic fibers span from the vestibular lining to the caudal margin of the lower lateral cartilage, and from the caudal edge of the lower lateral cartilage to the external alar skin. In the nasal ala midsection, trichrome stains reveal that skeletal muscle is located far beyond the lower lateral cartilage, close to the free alar margin. The soft triangle shows a distinct microanatomical structure, with heavy longitudinal condensations of elastin. These histologic findings have not been previously reported.

CONCLUSIONS

A distinct anatomical alar wall endoskeleton has been identified. It is obligatorily disrupted by specific rhinoplasty maneuvers when dissection is carried out over the lateral crura and into areas without cartilaginous support. This microanatomy may explain factors that contribute to postoperative alar wall retraction. Leaving this area undisturbed or performing adjunctive measures with rhinoplasty can provide structural support to the external valves, thus minimizing the risk of deformity.

Revisiting the Alar-Columellar Relationship: Classification and Correction

The alar-columellar relationship has tremendous aesthetic significance in the lower one-third of the nose. Aberrancies in the alar-columellar relationship detract from nasal aesthetics, and are classified into six types: type I, hanging columella; type II, retracted ala; type III, combination of a hanging columella and retracted ala; type IV, hanging ala; type V, retracted columella, and type VI, combination of a hanging ala and retracted columella. This article describes the methods for proper evaluation and diagnosis of aberrancies in the alar-columellar relationship, and current strategies to restore the ideal alar-columellar relationship. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Cephalic Rotation of the Nasal Tip

The position of the nasal tip holds important aesthetic significance. Cephalic rotation of the nasal tip is a frequent motivating factor for patients seeking rhinoplasty. The position of the nasal tip is a complex interplay of the size, morphology, and position of several anatomical components of the lower one-third of the nose. Cephalic rotation can be achieved by means of six different methods. The indirect methods promote passive cephalic rotation and include cephalic trim of the lower lateral cartilages, caudal trim of the upper lateral cartilages, and caudal septal trim. Direct methods involve precise repositioning of the domes and include shortening the lateral crura, lateral domal relocation, and the tip rotation suture. Used alone or in combination, these techniques and their subtle variations represent comprehensive and effective methods to achieve cephalic rotation of the nasal tip.

Alar Base Reduction and Alar-Columellar Relationship

Nasal base modification can improve nostril shape and orientation, reduce alar flaring, improve nasal base width, correct nasal hooding, improve symmetry, and create overall facial harmony. For the correction of alar rim deformities, careful examination, consultation, and analysis and consideration of the condition of the skin are essential. Understanding the ala and surrounding tissue, supporting the lower lateral cartilage, and selecting the proper technique produce functionally and aesthetically good results.

The Infratip Lobule Butterfly Graft: Balancing the Transition from the Tip Lobule to the Alar Lobule

The nasal alae and the soft-tissue triangles are delicate structures, the contours of which are largely dependent on soft tissue and the indirect influence of the lower lateral cartilages. Creating appropriate and continuous contour from the tip lobule to the alar lobule can be challenging. The alar contour graft is one reliable method of achieving predictable contour. However, alar contour grafts of ideal length may be scarce. The butterfly graft is a simple, reliable, and predictable method of providing support in the region of the soft triangle, and spans the region between the tip lobule and alar lobule, thereby balancing the transition between these regions.

Correction of saddle and short noses

PURPOSE OF REVIEW

The review summarizes the basic concepts and recent updates on the management of saddle and short noses, with a particular focus on the selection of septal reconstruction techniques and dorsal augmentation material.

RECENT FINDINGS

Different techniques have been reported for septal cartilage reconstruction, including various combinations of extended spreader and caudal septal extension grafts, as well as L-strut grafts. For dorsal augmentation, materials that help avoid costal cartilage warping including, diced costal cartilage with or without fascia, costal cartilage obtained by oblique cutting, diced conchal cartilage with perichondrial attachments, and lipofilling of the nasal dorsum have been reported.

SUMMARY

The article highlights the importance of rebuilding the septal cartilage support system by the proper use of costal cartilage and selection of an appropriate technique for the successful management of saddle and short noses. In addition, the importance of selecting suitable dorsal augmentation materials and other adjunctive maneuvers are emphasized.

Auto-Rim Flap Technique for Lateral Crura Caudal Excess Treatment

BACKGROUND

There are many variables that influence nose tip harmony. Even in a rhinoplasty that appears successful in profile, one may see nostril asymmetries, alar retractions, or irregularities in the soft triangle, and patients express their dissatisfaction with these simple deformities.

OBJECTIVES

In this study, we define the ratio of caudal and cephalic excess of the lower lateral cartilage. We evaluate whether it is possible to eliminate nostril asymmetries and alar retractions by means of supporting the facet polygon with the help of a lower lateral cartilage auto-rim flap, a technique we have developed in our rhinoplasties.

METHODS

The auto-rim flap was used successively on 498 primary rhinoplasty patients on whom the same surgeon operated between May 2013 and June 2015, performing marginal incisions.

RESULTS

Of the 498 patients in the series, only 1 of the first 10 required a revision due to tip asymmetry related to the auto-rim flap. A minimal nostril asymmetry that did not require intervention occurred in 10 patients. In none of the patients could an increased alar retraction be seen postoperatively. All patients exhibited alar cartilage in the anatomically correct position.

CONCLUSIONS

With the auto-rim flap technique, a part of the caudal excess of the alar cartilage remains as a flap in the facet region; therefore, there is no need in the cephalic region to perform more of an excision than what is strictly necessary.

LEVEL OF EVIDENCE

4 Therapeutic.

Simple Correction of Alar Retraction by Conchal Cartilage Extension Grafts

Background

Alar retraction is a challenging condition in rhinoplasty marked by exaggerated nostril exposure and awkwardness. Although various methods for correcting alar retraction have been introduced, none is without drawbacks. Herein, we report a simple procedure that is both effective and safe for correcting alar retraction using only conchal cartilage grafting.

Methods

Between August 2007 and August 2009, 18 patients underwent conchal cartilage extension grafting to correct alar retraction. Conchal cartilage extension grafts were fixed to the caudal margins of the lateral crura and covered with vestibular skin advancement flaps. Preoperative and postoperative photographs were reviewed and analyzed. Patient satisfaction was surveyed and categorized into 4 groups (very satisfied, satisfied, moderate, or unsatisfied).

Results

According to the survey, 8 patients were very satisfied, 9 were satisfied, and 1 considered the outcome moderate, resulting in satisfaction for most patients. The average distance from the alar rim to the long axis of the nostril was reduced by 1.4 mm (3.6 to 2.2 mm). There were no complications, except in 2 cases with palpable cartilage step-off that resolved without any aesthetic problems.

Conclusions

Conchal cartilage alar extension graft is a simple, effective method of correcting alar retraction that can be combined with aesthetic rhinoplasty conveniently, utilizing conchal cartilage, which is the most similar cartilage to alar cartilage, and requiring a lesser volume of cartilage harvest compared to previously devised methods. However, the current procedure lacks efficacy for severe alar retraction and a longer follow-up period may be required to substantiate the enduring efficacy of the current procedure.

Rhinoplasty Complications and Reoperations: Systematic Review

Introduction This article is related to complications of rhinoplasty and its main causes of reoperations.

Objectives The objective of this study is to perform a systematic review of literature on complications in rhinoplasty.

Data Synthesis The authors conducted a survey of articles related to key terms in the literature by using three important databases within 11 years, between January 2002 and January 2013. We found 1,271 abstracts and selected 49 articles to this review.

Conclusion The main results showed that the number of primary open rhinoplasty was 7902 (89%) and 765 closed (11%) and the percentage of reoperations in primary open complete rhinoplasties was 2.73% and closed complete was 1.56%. The statistical analysis revealed a value of p = 0.071. The standardization of terms can improve the quality of scientific publications about rhinoplasty. There is no difference between primary open or closed rhinoplasty techniques in relation to reoperations.

A Practical Approach to Rhinoplasty

Rhinoplasty continues to be one of the most commonly performed aesthetic surgical procedures. Over the past 25 years, the open approach has increased in popularity and is the focus of this article. The principles for successful rhinoplasty include comprehensive clinical analysis and defining rhinoplasty goals, preoperative consultation and planning, precise operative execution, postoperative management, and critical analysis of one's results. Systematic nasal analysis is critical to establish the goals of surgery. Techniques to address the nasal dorsum, nasal airway, tip complex, alar rims, and bony vault that provide consistent results are discussed.

Correction of Alar Retraction Based on Frontal Classification

Among the various types of alar deformations in Asians, alar retraction not only has the highest occurrence rate, but is also very complicated to treat because the ala is supported only by cartilage and its soft tissue envelope cannot be easily stretched. As patients' knowledge of aesthetic procedures is becoming more extensive due to increased information dissemination through various media, doctors must give more accurate, logical explanations of the procedures to be performed and their anticipated results, with an emphasis on relevant anatomical features, accurate diagnoses, detailed classifications, and various appropriate methods of surgery.

Repositioned lateral crural flap technique for cephalic malposition in rhinoplasty

BACKGROUND

Cephalic malposition of the lower lateral cartilage (CMLLC) is a relatively common anatomical variant, particularly in Middle Eastern patients. The characteristics of CMLLC include long alar creases, a boxy and ball-shaped nasal tip, parenthesis tip deformity and external valvular incompetence. The gold standard for correcting CMLLC is the lateral crural strut graft (Gunter graft), but many patients experience problems after this technique.

OBJECTIVE

To evaluate the efficacy of the repositioned lateral crural flap (RLCF) technique in correcting CMLLC, and to discuss the cosmetic and functional results.

METHODS

In the present study, 123 primary septorhinoplasty operations using the RLCF technique were performed between May 2012 and March 2013. The mean follow-up period was 11.4 months (range nine to 24 months). Four parameters were measured and compared pre- and postoperatively: the angle between the line connecting the maximum convexity of the lower lateral cartilage (LLC) to the tip-defining point and midline on each side (angle of rotation); the total distance between the maximum convexity of LLC right and left to midline (representing the size of the parenthesis deformity); satisfaction scale rating of the patients' nasal tip appearance; and the satisfaction scale rating of patients' breathing through their nostrils.

RESULTS

The mean angle of the LLC to the midline significantly increased and the mean distance between the maximum convexities was significantly reduced, indicating correction of the malposition and reduction of the parenthesis deformity, respectively. The mean satisfactory scale ratings of nasal tip appearance and breathing quality were also significantly improved.

CONCLUSION

CMLLC can be corrected using the RLCF technique, resulting in both aesthetic and functional improvements.

Repositioned lateral crural flap technique for cephalic malposition in rhinoplasty

Background

Cephalic malposition of the lower lateral cartilage (CMLLC) is a relatively common anatomical variant, particularly in Middle Eastern patients. The characteristics of CMLLC include long alar creases, a boxy and ball-shaped nasal tip, parenthesis tip deformity and external valvular incompetence. The gold standard for correcting CMLLC is the lateral crural strut graft (Gunter graft), but many patients experience problems after this technique.

Objective

To evaluate the efficacy of the repositioned lateral crural flap (RLCF) technique in correcting CMLLC, and to discuss the cosmetic and functional results.

Methods

In the present study, 123 primary septorhinoplasty operations using the RLCF technique were performed between May 2012 and March 2013. The mean follow-up period was 11.4 months (range nine to 24 months). Four parameters were measured and compared pre- and postoperatively: the angle between the line connecting the maximum convexity of the lower lateral cartilage (LLC) to the tip-defining point and midline on each side (angle of rotation); the total distance between the maximum convexity of LLC right and left to midline (representing the size of the parenthesis deformity); satisfaction scale rating of the patients' nasal tip appearance; and the satisfaction scale rating of patients' breathing through their nostrils.

Results

The mean angle of the LLC to the midline significantly increased and the mean distance between the maximum convexities was significantly reduced, indicating correction of the malposition and reduction of the parenthesis deformity, respectively. The mean satisfactory scale ratings of nasal tip appearance and breathing quality were also significantly improved.

Conclusion

CMLLC can be corrected using the RLCF technique, resulting in both aesthetic and functional improvements.

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.

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.

Are grafts necessary in rhinoplasty? Cartilage flaps with cartilage-saving rhinoplasty concept

BACKGROUND

Cartilage grafts are used routinely in rhinoplasty, but are they necessary? Can we support the normal anatomy by preserving and transposing the adjacent tissues? In this study we hypothesize that during rhinoplasty, cartilage flaps can give adequate support and may decrease the need for cartilage grafts.

METHODS

Included in this study were 147 patients who underwent an open rhinoplasty technique under general anesthesia between January 2010 and May 2012. Mean operative time was 73 min (range=44-120 min). After dissection and septoplasty (if needed), we performed dorsal bone and septal reductions. Following reduction, upper lateral cartilage superior segments were preserved and turned inward as cartilage flaps to replace the spreader grafts. Lower lateral cartilage cranial parts were not excised and were slid over the caudal part to replace the alar strut grafts. Cartilage from the caudal nasal septum was not excised; instead, lower lateral cartilages were cephaloposteriorly displaced with a tongue-in-groove technique to support the nasal tip.

RESULTS

Mean follow-up time was 19.6 months (6-30 months). All patients but 12 were satisfied or completely satisfied with the results. Among the 12 unsatisfied patients, four complained of a one-sided inverted-V deformity (secondary spreader grafts were added), three had supratip deformity (secondary additional dorsal septal excisions), two demanded extra tip definition (secondary tipoplasty), two were unhappy with the bone symmetry (secondary osteotomies), and one complained of hanging columella (secondary excision from the caudal septum).

CONCLUSIONS

Cartilage flaps have some advantages over cartilage grafts. First, graft harvest is not needed in the former; second, because flaps are a part of the normal anatomy, they provide a good tissue match, making fixation easier. However, the tongue-in-groove technique cannot be used in patients who do not need caudal excision, and cartilage flaps can be inadequate in some patients who may need additional grafts.

EBM LEVEL 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 .

Correction of asian short nose with lower lateral cartilage repositioning and ear cartilage grafting

Supplemental Digital Content is available in the text.

Background:

Asians with short nose lack the cartilage needed to extend the length of the nose. A rhinoplasty technique using lower lateral cartilage (LLC) repositioning and ear cartilage grafting allows for sufficient nasal lengthening and nasal tip mobility in the correction of short nose in Asians.

Methods:

Short nose was classified into 3 subtypes: type I, II, or III. During LLC repositioning, the LLC was separated from surrounding retaining structures, except at the footplate. The LLC was approximated medially and advanced with a Medpor strut. A silicone dorsal implant was inserted to suit the newly projected nasal tip. An ear cartilage onlay graft or ear cartilage extension graft was applied to further project and enhance the nasal tip and columella.

Results:

Of the 854 primary rhinoplasty procedures performed on Asian patients between January 2008 and December 2011, 295 were performed on patients with short nose. LLC repositioning and ear cartilage onlay grafting were performed on 228 patients. LLC repositioning and ear cartilage extension grafting with or without ear cartilage onlay grafting were performed on 67 patients. Short nasal tip, alar retraction, and columellar retraction were corrected. Wound dehiscence with marginal necrosis occurred in 7 patients. One patient developed nasal infection.

Conclusions:

LLC repositioning and ear cartilage grafting aid in the correction of short nose in Asians. With LLC repositioning and ear cartilage grafting, the nasal tip can be positioned in accordance with the patient’s anatomic limits. The entire nasal tip and columella can be lengthened, while the tip maintains its mobility.

Hypoplastic lateral crus causing alar retraction and underprojected nasal tip: correction with multiple grafts

A case of severe alar retraction and underprojected nasal tip due to hypoplastic lateral crura was successfully treated using a columellar strut graft, lateral crus replacement graft, and lateral crus caudalization graft and Medpor implant. 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 at www.springer.com/00266.

New classification for correction of alar retraction using the alar spreader graft

BACKGROUND

Identifying the cause of alar retraction is essential for proper correction of this deformity. In secondary surgery, aimed primarily at cephalic orientation and medialization of the lateral crus, corrections involving spreading and lateralization of the lateral crus can achieve a more horizontal orientation. In their clinic, the authors have practiced the use of an alar spreader graft to support the spread of the lateral crus. For the lateral crus to move freely without any resistance, it is critical to release the nasal hinge and pyriform ligament. A frontal view of the alar notching and the direction of the lateral crus are highly important factors needed to determine the cause of alar retraction. This report describes a new classification system for alar retractions viewed from the front to aid in determining the cause of the retraction and the surgical management.

METHODS

From March 2008 to July 2010, 31 alar retractions were corrected using alar spreader grafts for patients showing clear alar retractions in frontal views.

RESULTS

Satisfactory results without severe complications were obtained in 30 cases, with undercorrection in only 1 case. The alar cartilage was completely released to facilitate lateralization and caudal mobilization. An alar spreader graft then was used to support the lateral crus until a biologic scar cast was formed.

CONCLUSION

The use of alar spreader grafts to correct alar retractions provided consistently good results. The attempt also was made to enhance the treatment strategy based on this classification system derived from frontal views of alar retraction.

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 at www.springer.com/00266 .

Rhinoplasty

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Discuss desired preoperative aesthetic and functional assessment of the postsurgical nose with rhinoplasty patients. 2. Identify factors that have the potential to affect procedural outcomes. 3. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function. 4. Recognize and manage complications following rhinoplasty.

SUMMARY

Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery. Over the past 20 years, the trend has shifted away from ablative techniques involving reduction or division of the osseocartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. Accurate preoperative systematic nasal analysis and evaluation of the nasal airway, along with identification of both the patient's expectations and the surgeon's goals, form the foundation for success. Intraoperatively, adequate anatomical exposure of the nasal deformity; preservation and restoration of the normal anatomy; correction of the deformity using incremental control, maintenance, and restoration of the nasal airway; and recognition of the dynamic interplays among the composite of maneuvers are required. During postoperative recovery, care and reassurance combined with an ability to recognize and manage complications lead to successful outcomes following rhinoplasty.

Patient complaints with primary versus revision rhinoplasty: analysis and practice implications

BACKGROUND

Rhinoplasty patients often present with specific concerns and are frequently exacting in their demands and expectations of the surgical experience.

OBJECTIVES

The authors assess the presenting complaints expressed during the rhinoplasty consultation process and compare the presentations of primary versus revision rhinoplasty patients.

METHODS

A retrospective review of 400 consecutive rhinoplasty patients was performed. Demographic information and patient concerns regarding nasal appearance and function were recorded. Complaint frequencies (as well as rank order) were compared between primary and revision patients. Statistically significant associations were compared in more detail through logistic regression models.

RESULTS

Primary rhinoplasty patients were significantly more likely to cite "too large" and "dorsal hump" as motivating concerns. Conversely, revision rhinoplasty patients were far more likely to cite concern regarding a "crooked nose," "tip asymmetry," "wide or large nostrils," "dorsal sloop," and "columellar show." Revision rhinoplasty patients also complained of issues such as "alar retraction," "pointy tip," and "nasal scarring," which were almost negligible in frequency in the primary rhinoplasty group.

CONCLUSIONS

Patients presenting for primary rhinoplasty commonly seek a smaller, more refined nasal appearance. Patients with prior rhinoplasty operations are far more likely to raise concern regarding crookedness or asymmetries. By comparing the presentations of primary and revision rhinoplasty patients-and delineating the common indications for revision operations-novice rhinoplasty surgeons may be able to avoid certain pitfalls at the outset, thereby reducing their revision rates. The data may also assist surgeons in developing a more targeted approach to the consultation process in the revision setting.

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.

Chicken sternal cartilage for simulated septal cartilage graft carving: a rhinoplasty educational model

BACKGROUND

In rhinoplasty, cartilage is often harvested from the nasal septum and meticulously carved into delicate grafts designed to reshape and strengthen the nasal osteocartilaginous framework. Proficiency at this task develops with experience in the clinical setting.

OBJECTIVE

The author offers a simulated educational model designed to provide rhinoplasty surgeons with increased preclinical experience in cartilage graft carving.

METHODS

This model relies on inexpensive, food-grade chickens, which may be purchased at any grocery store. Four whole chickens were dissected to expose and harvest the sternal (breast/keel) cartilage. A technique was developed for preparing the cartilage to approximate the shape and dimensions of human septal cartilage. Measurements were made to demonstrate similarities between the model material and the human septum.

RESULTS

The average weight of the chickens was 4.27 lb. The average cartilage height, length, and thickness were 2.36 cm, 6.13 cm, and 3.4 mm, respectively. This size compared favorably with typical septal harvest pieces, which had both heights and lengths of 2.5 cm and thicknesses of 3.25 mm. The author found that one sternal cartilage piece could be employed to carve two spreader grafts, a columellar strut graft, a tip graft, and two alar rim cartilage grafts. The performance of the avian cartilage was subjectively very similar to that of septal cartilage. Furthermore, two pieces of the sternal cartilage could be glued together and fastened within a model of a human skull to replicate the cartilaginous septum in situ. This construct was employed for demonstrations of actual septal cartilage harvest.

CONCLUSIONS

Carving septal cartilage into grafts is a difficult process. Precision and improved results increase with clinical experience on human patients, but this cadaveric avian (chicken) model provides an opportunity for simulated surgical training on a very similar tissue type at a very low cost. This model has the potential to improve human outcomes by providing increased practice opportunities in a procedure that requires precision and artistry for the formation of reproducible geometric graft shapes.

Preventing alar retraction by preservation of the lateral crus

BACKGROUND

Resecting the cephalic component of the lateral crus in an attempt to reduce tip bulbosity has the potential to aggravate and/or cause alar retraction. It is a more serious problem for those patients who exhibit borderline alar retraction.

METHOD

Fourteen primary rhinoplasty patients with borderline alar/columellar relationships for alar retraction formed the study. They did not warrant frank treatment of alar retraction but did exhibit tip bulbosity. An "island" of cephalic lateral crus was developed by an intercartilaginous incision and another 6 mm cephalic to the caudal border of the lateral crus. One or more mattress sutures were placed in the main body of the lateral crus to stiffen and straighten it. The "island" of cephalic crus was then slipped under the main body of the lateral crus.

RESULTS

At 11 months to 2(1/2) years, 13 of the 14 patients demonstrated no significant change in their preoperative alar/columellar relationships. Bulbosity was corrected in all patients. One patient, however, required a revision using an alar contour rim graft. The mean preoperative alar-nostril axis measurement was 1.48 mm (range, 1.3 to 1.9 mm) in contrast to a mean postoperative measurement of 1.71 mm (range, 1.5 to 2.2 mm). A one-tailed paired t test indicated no statistically significant difference between preoperative and postoperative values.

CONCLUSIONS

The cephalic part of the lateral crus can act as a lateral crural strut to maintain the ala in a more caudal position. The technique is useful for borderline alar retraction and when lengthening the short nose for which there is a need to preserve side wall length.

Anatomical characteristics of the conchal cartilage with suggested clinical applications in rhinoplasty surgery

BACKGROUND

Numerous cartilage grafts from a number of donor sites have been described, each with a different shape and size. These donor sites include the nasal septum, costal chondral cartilage, and the conchal bowl. Although harvests from the conchal bowl are commonly-employed, the techniques have been minimally-described in the literature, particularly as it applies to rhinoplasty.

OBJECTIVES

The authors identify differences in the conchal bowl cartilage parameters that could aid in the planning and harvesting of conchal grafts during augmentation rhinoplasty.

METHODS

The authors dissected ears from fourteen cadavers (eight females and six males), ranging between 59 and 77 years of age. The conchal bowls were isolated, after which a reference point or was marked at the junction of the helical root and the conchal extension of the helical root. A cartilage grid was mapped out at 3-mm interval divisions with a horizontal limb axis parallel to the helical root extension and a vertical limb axis perpendicular to the latter. Conchal cartilage width, height, and thickness were then measured. Axial tissue slices were harvested and histologic preparations completed with hemotoxylin and eosin (H&E) staining to delineate microscopic characteristics of the cartilage.

RESULTS

Maximum conchal bowl width ranged from 1.9 to 2.9 cm and was widest on average over the cymba (2.4 ± 0.3 cm). Maximum conchal bowl height ranged from 1.7 to 3.1 cm and was greatest on average over the region posterior to the junction of the helical root and conchal bowl (2.4 ± 0.5 cm). Conchal bowl thickness ranged from 1.9 to 4.4 mm and was observed thickest over both the conchal extension of the helical root (3.5 ± 0.4 mm) as well as over a distinct region in the inferior-anterior aspect of the cavum (3.7 ± 0.9 mm). No difference in thickness was observed between the conchal extension of the helical root (3.5 ± 0.4 mm) and the distinct region in the inferioranterior aspect of the cavum (3.7 ± 0.9 mm; P > .05). Naturally-occurring cartilaginous divisions were appreciated on histologic specimens located at the junction of the cavum and external auditory meatus and at the junction of the helical root and conchal extension of the helical root.

CONCLUSIONS

The results, examination, and outline of conchal bowl parameters from cadaver cartilage demonstrated in this article will aid the surgeon in effectively obtaining the appropriate cartilage grafts for placement during rhinoplasty.

Diagnosis and correction of alar rim deformities in rhinoplasty

Recognition of alar rim deformities is an important component of the preoperative analysis of the nose. Correction of these deformities improves the esthetic balance of the nose and has an added benefit of improving the function of the external nasal valve. Classification systems have been proposed to enable surgeons to more accurately diagnose alar deformities. These classification systems help guide surgeons as to the appropriate surgical procedure to correct a problem. The purpose of this article is to review the proposed classification systems for alar rim deformities and review the specific surgical techniques that have been proposed for each of the deformities.

Cartilage Z plasty on lateral crus for treatment of alar cartilage malposition

BACKGROUND

Alar cartilage malposition is an anatomical variation. Axis of the lateral crus lies cephalically and can be parallel to the cephalic septum. The characterised findings of the malposition are broad and bulbous nasal tip, abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities and associated external valvular incompetence. This article presents a new technique for the repositioning of the lateral crus in this article.

METHODS

Open rhinoplasty was conducted. A cartilage Z plasty was performed on the lateral crus of the alar cartilage to treat for malposition. The 14 women and 8 men included in the study had an average age of 27 years (range, 18-46 years). The average follow-up period was 12 months (range, 4-20 months).

RESULTS

Alar cartilage malposition was successfully corrected in patients with aesthetic and functional improvements.

CONCLUSIONS

Cartilage Z plasty can effectively correct alar cartilage malposition. Advantages of this technique can be listed as follows: it does not require extra graft material and protects the lateral crural complex; it does not disrupt movements of the alar muscles and can also serve to adjust projection of the nasal tip.