Cephalic Trim Research Articles

Development and Evaluation of a High-Fidelity Rhinoplasty Simulator.

Rhinoplasty is a challenging procedure with a steep learning curve. Surgical simulators provide a safe platform to gain hands-on experience without compromising patient outcomes. Therefore, rhinoplasty is an ideal procedure to benefit from an effective surgical simulator. A high-fidelity rhinoplasty simulator was developed using three-dimensional computer modeling, three-dimensional printing, and polymer techniques. The simulator was tested by six surgeons with experience in rhinoplasty to assess realism, anatomic accuracy, and value as a training tool. The surgeons performed common rhinoplasty techniques and were provided a Likert-type questionnaire assessing the anatomic features of the simulator. A variety of surgical techniques were performed successfully using the simulator, including open and closed approaches. Bony techniques performed included endonasal osteotomies and rasping. Submucous resection with harvest of septal cartilage, cephalic trim, and tip suturing, as well as grafting techniques including alar rim, columellar strut, spreader, and shield grafts, were performed successfully. Overall, there was agreement on the simulator's anatomic accuracy of bony and soft-tissue features. There was strong agreement on the simulator's overall realism and value as a training tool. The simulator provides a high-fidelity, comprehensive training platform to learn rhinoplasty techniques to augment real operating experience without compromising patient outcomes.

Use of cephalic trim cartilages from lower lateral cartilage to elongate short nose

In our study, we used cephalic trim cartilage from LLC uniting strategies to be compelling in amending short nose, with a low occurrence of complications. Preferences of this procedure incorporate extension of the whole nasal tip and ala, which brings about more far reaching and proportioned nasal length. The versatile nasal tip is kept up by sufficiently liberating the holding powers of the LLC while offering enough underlying help.

An Update on the Surgical Management of the Bulbous and Boxy Tip.

The bulbous and box tips are two common morphologies encountered in rhinoplasty. Nasal tip reshaping is a challenging aspect of rhinoplasty. Understanding the classifications of nasal tip morphologies aids when performing a nasal-facial analysis. The management algorithm for both tip morphologies shares various techniques. These techniques include but are not limited to cephalic trim, transdomal sutures, and interdomal sutures. A graduated approach to managing the variations in bulbous and boxy tips will help in achieving consistent results. New concepts applied to the management include supporting alar rims with alar contour grafts, closing dead space through a series of techniques, and managing the soft-tissue envelope, which is often in excess.

Cephalic lateral crural advancement flap

BackgroundIn lower lateral cartilage (LLC) surgery, cephalic trimming poses risks for the collapse of the internal and external nasal valves, pinched nose, and drooping deformity. The cephalic lateral crural advancement (CLCA) technique presented herein was aimed at using a flap to increase nasal tip rotation and support the lateral crus, in addition to the internal and external nasal valves, by avoiding grafts without performing excision.MethodsThis study included 32 patients (18 female and 14 male) and the follow-up period for patients having undergone primer open rhinoplasty was 12 months. The LLC was elevated from the vestibular skin using the CLCA flap. A cephalic incision was performed without cephalic trimming. Two independent flaps were formed while preserving the scroll ligament complex. The CLCA flap was advanced onto the lower lateral crus while leaving the scroll area intact. The obtained data were analyzed retrospectively.ResultsThe mean age of the patients was 31.6 years (range, 20–51 years). The Rhinoplasty Outcome Examination scores after 12 months varied from 90 to100 points, and 93% of patients reported perfect satisfaction. At a 1-year follow-up, the patients’ nasal patency (visual analogue scale) rose from 4.56±1.53 (out of 10) to 9.0±0.65 (P<0.001).ConclusionsThe CLCA flap led to better nasal tip definition by protecting the scroll area, increasing tip rotation, and supporting the internal and external nasal valves without cephalic excision.

Endonasal Cephalic Trim: Our Surgical Technique

Endonasal Cephalic Trim: Our Surgical Technique

Management of the Cephalic Positioning of the Lower Lateral Cartilage in Modern Rhinoplasty: An Algorithmic Approach.

Cephalic positioning of lateral cruras literally means that the cartilage does not support the nasal rim. Cephalic positioning is a relatively common anatomic variant of lower lateral cartilages that shows an extremely vulnerable rhinoplasty patient. In these patients, any reductive technique, such as cephalic trimming without compensation, worsens the situation and may lead to esthetic failures and airway compromise. True cephalic malpositioning needs to be diagnosed from pseudomalpositions preoperatively. The presence of the pseudomalposition does not mean that it can be ignored. Either malposition or pseudomalposition is best diagnosed and considered in the treatment plan.

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

To evaluate the lateral nasal wall stability, nasal function, and cosmesis when creating an aesthetically pleasing nasal tip subunit utilizing lateral crus (LC) altering procedures. Retrospective cohort. In this retrospective cohort study, cosmetic rhinoplasty patients undergoing LC procedures with available lateral wall insufficiency (LWI) scores were included. An LWI grading system was used to evaluate internal (zone 1) and external (zone 2) nasal valves objectively. Secondarily, Nasal Obstruction Symptom Evaluation (NOSE) Score, Visual Analog Scale (VAS) and Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) results were evaluated. Based on the LC intervention, the cohort was divided into six groups: lateral cural strut graft (LCSG), mini-LCSG, lateral crural overlay (LCO) with and without additional support, cephalic trimming, and cephalic turn-in flaps. Subjects undergoing LCO with and without support, LCSG, and mini-LCSG showed significant improvement in zone 1 LWI (P = .042, P = .041, P < .001, and P < .001, respectively), while cephalic trimming and turn-in/hinged flaps had no effect. Subjects undergoing LCO with support and LCSG showed significant improvement in zone 2 LWI (P = .022, P = .004), while LCO without support, mini-LCSG, cephalic trimming, and turn-in flaps showed no effect on LWI. The SCHNOS-C and VAS-C showed significant improvement in all subgroups (P < .05) when comparing pre- to postoperative values. Alar-spanning sutures did not significantly change zone 1 scores but did conceal zone 2 improvements in LCSG and LCO with support groups. Selected LC procedures are robust techniques for improving tip cosmesis independently without compromising nasal lateral wall stability. Some LC procedures can improve nasal valves patency in tip surgery. Laryngoscope, 131:E1830-E1837, 2021.

Primary presentation of a novel cartilage tweezer for simplification of alar cartilage cephalic resection—preliminary results

Aesthetic rhinoplasty can be quite challenging with the possibility of cartilage damage during manipulation, while there is a relevant risk of injury to the surgeon. To minimize both risks to the patient and surgeon, this paper presents a new cartilage tweezer, which also allows more precise handling during cartilage resection. At its distal end, the developed tweezer consists of a bent section, which forms a narrow scalpel guide for cartilage dissection with a partly overlapping branch design to improve accuracy during resection. At the apex of the tweezers’ cartilage guide, a ruler ensures meticulous measurement, which facilitates precise excision without the risk of over resection, which results in the preservation of cartilage stability. Additionally, the design includes an adjustable radius of the curvature of the two gripping jaws, allowing a variable resection size of lower lateral cartilage, without causing any crushing or bruising of the non-resected cartilage. The tweezer was tested during 21 functional-aesthetic nose surgeries at the department for Plastic and Reconstructive Surgery and Otorhinolaryngology of the Klinik Landstrase Hospital in Vienna. The presented instrument simplifies cartilage incision and the removal of excess cartilage during rhinoplasty, especially during cephalic trimming of the lower lateral cartilages. Level of evidence: Level V, therapeutic study.

A Modified Closed-Open Approach as Part of a Graduated and Integrative Approach to Rhinoplasty.

Introduction Open versus closed approach in rhinoplasty is a frequently debated topic in aesthetic plastic surgery. Although good results can often be achieved with either technique, both have unique advantages and disadvantages. In this investigation, we present our experiences of a modified closed-open approach that has been applied on 482 complex primary and secondary rhinoplasties. Three representative cases are described in more detail. Materials and Methods The procedure begins as a closed approach through an intracartilaginous incision allowing cephalic trimming of the lateral crura, dorsal rasping, and/or excision. Patients requiring extensive nasal tip maneuvers are subjected to exposure of the alar cartilage framework through a transcolumellar/limited marginal incision. This provides not only adequate exposure of the alar cartilages but also easy access to the septum. Conclusion In our hands, this approach is easy and expeditious. It requires less tip dissection, and therefore may avoid the prolonged postoperative edema that is often a consequence of open or extended closed tip delivery approaches.

Optimising Results of Nasal Tip Rotation Applying Combination of Nasolabial Angle and Lip-Columellar Angle in Tandem in Patients Operated by "Cock-up" Alar Cartilage Flaps Technique.

Background Setting the angle of tip rotation is of utmost importance in achieving satisfactory results in rhinoplasty. Conventionally the upward rotation of the tip requires shortening of the septum by caudal resection and shortening of the lateral walls by cephalic trim of the alar cartilages. The results are usually assessed subjectively. We describe the use of objective parameters to ensure accuracy of nasal tip rotation in patients operated with “cock-up” alar cartilage flaps, a modification of the cephalic trim. Methods Fifteen patients with a long nose having adequate width of lateral crura, desiring a shorter nose with upward tip rotation, were included in the study. Values of preoperative and desired nasolabial angle (from morphed images), and the derived columellar–labial angle were documented. Nasal tip rotation was set to the derived angle and maintained using cock-up alar cartilage flaps. The outcome was evaluated by digital measurements of the nasolabial angle and patients’ feedback by Rhinoplasty Outcome Evaluation (ROE) score. Results Satisfactory tip rotation and an aesthetic supratip area could be achieved. The difference in preoperative and postoperative nasolabial angles was statistically significant (p value < 0.0001). The difference in desired and the obtained nasolabial angle was not significant (p value 0.085). The results were maintained on subsequent follow-up. Conclusion Application of angles in practice and use of K-wire template helps us achieve accurate and consistent results. Cock-up flap is an effective technique—to obtain an open nasolabial angle and a desirable supratip region by making use of tissues otherwise discarded.

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.

Abstract: Changing Nasal Tip Projection Via Purposeful Manipulation of the Medial Crura: A Surgical Experience with Resecting the “Unresectable”

GOALS/PURPOSE: A belief exists that dissection and resection of the medial crura should be discouraged to avoid compromise of the tip support. We believe that judicious resection of the columellar portion of the medial crura can be an effective and predictable technique to control or reduce tip projection. This is pertinent in cases of tip overprojection, increased columellar show, or intraoperative findings of significantly buckled medial crura, where this technique allows for greater precision in controlling tip projection. Concern for loss of tip support can be obviated by buttressing the resulting structure with a columellar strut graft. We describe the routine use of dissection and resection of medial crura by the senior author (TAM) and present a brief review of the results. METHODS/TECHNIQUE: METHODS: A single institution, retrospective review of all consecutive patients who underwent rhinoplasty with resection of the medial crura by the senior author (TAM) during a single year was conducted. TECHNIQUE: All rhinoplasties were performed using an open technique. After conservative lateral crura resection in most cases, the nose is opened using a combination of blunt and sharp sub-mucoperichondrial dissection. Septoplasty is performed via a hemitransfixion incision, followed by dorsal rasping. The medial crura are dissected from the soft tissue envelope and the tip is shaped with a routine cephalic trim of the lateral crura and any dome suture maneuvers necessary. The projection of the tip is assessed and the appropriate (usually 3-5mm) amount of medial crura is resected from the mid-columellar segment. The columellar strut graft is placed and the cut ends of the crura are overlapped and sutured over the strut graft using 5-0 PDS. RESULTS/COMPLICATIONS: Nineteen patients matched inclusion criteria, with a mean age of 39 years old. Six patients (32%) had a history of a prior rhinoplasty procedure. In addition to resection of the medial crura, thirteen patients (68%) also had resection of their lateral crura. All patients underwent a septal resection and 18 (95%) received a columellar strut. Three (16%) patients had spreader grafts inserted and three (16%) patients had a tip graft placed. There were no complications in this series. Postoperative cosmesis was considered excellent by both patient and surgeon in all cases at mean follow-up of 11 months. CONCLUSION: Manipulation of the medial crura of the lower lateral cartilages is not inherently detrimental to tip support if performed judiciously and reinforced with a columellar strut graft acting as a buttress to the caudal medial crura. This technique is most useful to decrease tip projection or when tip projection is at goal, but domal shaping sutures would increase it and create over-projection. In both scenarios, resecting a portion of the mid-columellar medial crura leads to a predictable decrease in tip projection. We have not encountered any cases of support deficiency postoperatively. We encourage incorporating this technique to address over-projected noses and to prevent over-projection that may result from domal suture techniques.

Superior-Based Transposition Flap: A Novel Technique in Rhinoplasty.

The cephalic trimming of the lower lateral cartilage (LLC) is an attempt to reduce tip bulbosity; unfortunately, it has the potential to cause a pinched nose deformity and valve collapse. The author sought to use the superior-based transposition (ST) flap to reshape, relocalize, and reinforce the LLC as a support material for both internal and external valves with aesthetic corrections, leaving the scroll area untouched. A total of 367 patients (female, 215; male, 152) were operated with the presented technique. The ST flap was simply used to prepare a cartilage flap based on the scroll area in the cephalic portion of the LLC, and then this flap was advanced over the remaining LLC. The data were evaluated retrospectively. Functionally, the ST flap was used to reshape and support the LLC and the internal valve by keeping the scroll intact and increasing the internal valve angle. The support and suspension of the LLC with this novel technique improve the functional results and prevent complications such as stenosis of both the external and internal valve angles. Aesthetically, the convexity and concavity of the LLC could be fixed with the adaptation of these two surfaces in different angles, thereby achieving a narrower, refined, and aesthetically pleasing tip. This study demonstrates that the ST flap can be one of the main maneuvers performed during rhinoplasty for many purposes, such as reshaping and supporting the LLC, increasing the tip rotation, achieving more aesthetically pleasing tips, suspending the internal and external valves, and protecting the scroll area.

The impact of surgical manipulation on lower lateral cartilage stiffness

Cephalic trimming of the alar (or lower lateral) cartilage may cause weakening leading to external nasal valve collapse. Numerous methods have been proposed to combat this weakening in order to maintain lateral crural stiffness. The purpose of this study was to quantify the effect of mucosal stripping, cephalic trimming, cephalic turn-in flap, and lateral crural strut grafting on lateral crural stiffness. In situ cyclic compressive loading was performed on eight lateral crura in 4 fresh frozen cadaveric specimens. Testing was performed on the unaltered degloved cartilage (intact) and following each of the following interventions: mucosal stripping, cephalic turn-in flap, cephalic trimming, and lateral crural strut grafting. Linear regression of the generated force-displacement curves was used to calculate stiffness. Each intervention was compared to the intact cartilage. Alar cartilage of all of the specimens demonstrated a linear response to compressive loading. Intact cartilage had a mean stiffness of 3.53 N/mm. Mucosal stripping and cephalic turn-in flaps yielded similar stiffness values to intact cartilage. Cephalic trimming reduced stiffness in all cases by a mean of 1.09 N/mm (p = 0.003). Lateral crural strut grafting significantly increased stiffness by a mean of 3.67 N/mm (p = 0.0001). Cephalic trimming leads to decreased lateral crural stiffness in cadaveric specimens. Cephalic turn-in flaps restore pre-trimmed stiffness, and lateral crural strut grafting increases overall stiffness of the cartilage. These findings should be considered in patients undergoing rhinoplasty, particularly if there are concerns regarding potential external valve collapse.

Lateral Crural Tensioning for Refinement of the Nasal Tip and Increasing Alar Stability: A Case Series.

AbstractThe objective of this study was to discuss the technical details and our experiences with lateral crural tensioning (LCT) in both functional and aesthetic rhinoplasties. A retrospective medical review was completed for all patients who underwent rhinoplasty with LCT from the years 2011 to 2014. The indications for LCT included correction of lateral crural convexity, boxy tip geometry, and dynamic collapse of the external nasal valve. The details of the rhinoplasty procedure and complications were evaluated. A total of 114 LCT rhinoplasty cases were included in this series. The most common adjunctive maneuvers included placement of spreader grafts (92% of cases) and alar rim grafts (78% of cases). Conventional classic cephalic trim was not performed in any subjects and conservative paradomal cephalic trim was performed in 48% of cases. As experience with the technique progressed, the use of onlay tip grafts decreased and the use of articulated rim grafts increased. Indications for revision were dissatisfaction with cosmetic outcome (4.4% of cases) and nasal obstruction (0.9% of cases). LCT combines traditional lateral crural steal with the use of a caudal septal extension graft to refine the broad tip and increase stability of the alar lobule. This maneuver is essentially cartilage sparing and does not rely on extensive grafting maneuvers that can reduce airway area.

A Modified Closed-open Approach As Part Of A Graduated And Integrative Approach To Rhinoplasty

Open versus closed approach in rhinoplasty is a frequently debated topic in aesthetic plastic surgery. Although good results can often be achieved with either technique, both have unique advantages and disadvantages. In this investigation we present our experiences of a modified closed-open approach which has been applied on 482 complex primary and secondary rhinoplasties. Three representative cases are described in more detail. Surgical method: The procedure begins as a closed approach through a intracartilaginous incision allowing cephalic trimming of the lateral crura, dorsal rasping and/or excision. Patients requiring extensive nasal tip maneuvers are subjected to exposure of the alar cartilage framework through a transcolumellar/limited marginal incision. This provides not only adequate exposure of the alar cartilages but also easy access to the septum. In our hands this approach is easy and expeditious. It requires less tip dissection, and therefore may avoid the prolonged postoperative edema which is often a consequence of open or extended closed tip delivery approaches.

Abstract: A New Modified Closed-Open Approach as Part of a Graduated and Integrative Approach to Rhinoplasty

BACKGROUND: Open versus closed approach in rhinoplasty is a frequently debated topic in aesthetic plastic surgery.1–3 Although good results can often be achieved with either technique, both have unique advantages and disadvantages. We present a new modified closed-open approach employed in selected cases that encompasses features of both. METHODS: The surgical approach is described in detail followed by clinical examples. Indications and limitations are discussed. The procedure begins as a closed approach through an intracartilaginous incision allowing cephalic trimming of the lateral crura and dorsal rasping and/or excision. Patients requiring extensive nasal tip maneuvers are dealt with exposure of the alar cartilage framework through a transcolumellar/limited marginal incision to provide adequate exposure of the alar cartilages as well as easy access to the septum. In our hands this approach is easy and expeditious. It requires less tip dissection, and therefore avoids the prolonged postoperative edema associated with open or extended closed tip delivery approaches. CONCLUSION: The modified closed-open technique circumvents the limitations of the closed approach by providing good exposure of the tip and septum without incurring the shortcomings of the open approach. In selected cases, it provides the surgeon with the opportunity to combine the advantages of both techniques. DISCLOSURE:No disclosures REFERENCES: 1. Daniel RK. Rhinoplasty: The First 100. In: Daniel RK, ed. Rhinoplasty. 1st ed. Boston: Little Brown; 1993: 321–80. 2. Tebbetts JB. Open and closed rhinoplasty (minus the “versus”): analyzing processes. Aesthet Surg J. 2006;26:456–9. 3. Perkins SW. The evolution of the combined use of endonasal and external columellar approaches to rhinoplasty. Facial Plast Surg Clin North Am. 2004;12:35–50.

Use of the "Septal T" as a Spacer and Conformer for a Properly Contoured Nasal Tip in Rhinoplasty.

The complex issue of obtaining an aesthetically pleasing and structurally stable nasal tip brings into play a vast array of maneuvers and techniques, often performed through an open approach.1 Although these approaches are numerous and different, they all share the attainment of a stable tip cartilaginous structure, and then, if necessary, some sort of refinement or camouflage on top. An obvious situation in which such camouflage is unnecessary is the thick-skinned patient for whom sharp definition intrinsically may be welcome. As epitomized by Daniel,2,3 the ideal tip configuration will usually resemble a gently opened diamond. A similar concept is found, often with different suture terminology, in the work of other well-known surgeons.4,5 After appropriate repositioning, tensioning, or stiffening of the lateral crura as necessary, transdomal and interdomal sutures will be used to appropriately shape the domes and allow the gentle anterior domal divergence that will be stabilized by posterior dome equalization sutures. Some final camouflage may be necessary at this point. Various grafts are commonly utilized for this purpose, including segments from the cephalic trim, intercrural soft tissue, crushed cartilage, or even deep temporal fascia if harvested for other reasons.6,7 A specific drawback that will oftentimes detract somewhat from the result of an otherwise well-executed rhinoseptoplasty is a residual V-shaped infralobular cleft, extending from between the domes to the middle and medial crura. This is obviously more evident with thin skin and can be bothersome to the patient preoperatively. In such a patient, the surgeon must note the necessity of gently filling the gap between the new domes, as well as the indentation in continuity that flows below the columellar lobular angle and resides between the medial crural segments along the columella. Beginning in 2014, the senior author (E.R.) noticed …

The Benefit of a Complete Cephalic Trim and the Importance of the Scroll Area.

Cephalic trimming of the lower lateral cartilage (LLC) of the nose is often performed to refine a broad nasal tip in the horizontal dimension. The focus of cephalic trimming remains the preservation of the width of the lateral crura and the cartilage remnant at the cephalic end of the LLC is usually left intact, which leads to inadequate cephalic trimming.The authors suggest that cephalic trimming should continue all the way to the cephalic end of the LLC and no remnant cartilage should be left in the scroll area. This would make it possible to reduce the bulk of the nasal tip in an acceptable manner. Trimming of the whole cephalic side of the LLC would disrupt the scroll area, allowing authors to assess rhinoplasty as a 2-stage surgical procedure: that is, nasal tip and middle vault.In conclusion, complete cephalic trimming without leaving any remnant cartilage in the scroll area is necessary for adequate nasal tip refinement, and disruption of the scroll area allows the rhinoplasty to be compartmentalized to achieve more desirable results in the middle vault and the nasal tip.

Role of the Cephalic Trim in Modern Rhinoplasty.

There have been a variety of techniques describing nasal tip refinement. The cephalic trim has long been accepted as a means for shaping the nasal tip, but it has been misinterpreted by many surgeons. The improper use of a cephalic trim poses potential long-term sequelae. During analysis of the nasal tip, several anatomic findings must be noted to ensure appropriate correction as well as to avoid pitfalls. These findings include the type of boxy tip or bulbous tip, cartilage strength, and the skin quality. The goal of this article is to describe five types of cephalic trim techniques to assist in refining the nasal tip and an algorithm for selection of the appropriate technique based on these anatomic findings.