External Rhinoplasty Approach Research Articles

Rare Case of Nasal Tip Schwannoma - A Case Report.

Schwannoma is a benign neurogenic neoplasm which is arising from schwann cells of peripheral nerve sheath. It can occur in anywhere in the body. Schwannoma of sinonasal tract is extremely rare. Here we report a rare case of schwannoma of nasal tip. A 45 year old male presented with a swelling of tip of the nose, causing cosmetic deformity with no other associated symptoms. Surgical excision of the mass done by using external rhinoplasty approach. Histolopathology report of specimen showed a well circumscribed schwannoma with Antoni A and Antoni B areas.

A Case of Squamous Cell Carcinoma of Nasal Septum Removed Through the External Rhinoplasty Approach

Primary tumors arising solely from the nasal septum are quite unusual. Moreover, malignant tumors arising from the nasal septum are rare and represent less than 9% of sinonasal malignancies. Of all reported cases of nasal septum carcinoma, squamous cell carcinoma is the most common type. Due to the rare prevalence, its clinical course and prognosis are not well established. In this article, we report a case of a 79-year-old male with nasal obstruction. Endoscopic examination showed an exophytic mass obstructing the right nasal cavity accompanied by polypoid mass in the left nasal cavity. Punch biopsy confirmed the diagnosis of squamous cell carcinoma by histopathology. Radiologic evaluation showed a large nasal cavity mass involving the nasal septum. The tumor was removed using the external rhinoplasty approach with a large septal resection, saving the nasal keystone area and the columella to prevent the external nose deformity.

Recurrent rare nasal tumour excised via external rhinoplasty approach

A 23-year-old girl presented to the outpatient clinic complaining of a painless slow growing lump on her nose for several months. She had a similar lump there which was operated one year ago. There was a well-defined, firm lump over the lateral nasal wall.Ultrasound scan confirm it’s a subcutaneous lump without deep extension. Excision was done via open rhinoplasty approachand the histology report came as a giant cell tumour of soft tissue.

Nasal Dermoids in Children: Factors Influencing the Distant Result

The aim of the study was to present a single institution’s treatment strategy for nasal dermoids and to identify factors influencing distant results. The study covered 24 surgically treated pediatric patients with nasal dermoids (NDs). The medical data concerning demographics, preoperative local inflammations and surgical procedures, form of the abnormality, imaging, surgical techniques, and a role of osteotomies and reconstructions were analyzed. The recurrence rates and distant aesthetic outcomes were assessed. The surgical approach included vertical incision in 21 patients, the external rhinoplasty approach in 2 cases, and bicoronal incision in 1 child. The intracranial extension was confirmed in 6 patients. Seven out of 8 cases with preoperative local inflammations and 3 out of 4 with secondary fistulization were < 4 years old. Nine patients required osteotomies. Three children required reconstruction of the nasal skeleton. None of the distant cosmetic results was described as hideous or unsatisfactory. The incidence of local inflammatory complications is unrelated to the age of the patients. The distant aesthetic result depends on both the initial extent of the disease and preoperative local conditions or interventions. Prompt surgical intervention is highly recommended.

Chondrosarcoma of the Nasal Septum

Chondrosarcoma of the nasal septum is a very rare malignant tumor in the head and neck region. To diagnose chondrosarcoma, it is challenging to obtain an exact initial impression just by simple physical examination. Therefore, imaging studies are useful in the initial assessment of chondrosarcoma. Pathological confirmation is necessary for a definitive diagnosis of chondrosarcoma. In the treatment of chondrosarcoma, complete surgical resection is most effective, but often difficult. We report a patient with chondrosarcoma misdiagnosed with nasal septal deviation causing nasal obstruction. The patient underwent endoscopic surgical resection via an external rhinoplasty approach. The pathological diagnosis of the patient was chondrosarcoma with pathological Grade 1. The patient has been regularly followed up to date without recurrence.

Midline Nasal Tip Sinus

Introduction Congenital midline sinus over tip of nose is a rare clinical presentation. Accurate diagnosis should be done to rule out intracranial extension and to prevent recurrence. Appropriate surgical approach depends upon location, extent and degree of intracranial extension. Management entails complete surgical excision of sinus tract. We discuss a rare case, where external rhinoplasty approach was used for excising recurrent sinus and patient was disease free. Case Report A 29 year old male patient with midline nasal tip sinus presented in our institute with history of opening over tip of nose since childhood associated with recurrent episodes of discharge from opening. Our objective is to present clinic-radiological-pathological profile of congenital nasal sinus along with review of literature. Discussion Nasal dermoid is rare embryological anomaly of ectodermal and mesodermal origin. Radiological imaging should be considered to rule out any intracranial extension. Goal of management is complete surgical excision with meticulous pre-operative and surgical planning to avoid complications and recurrence. External rhinoplasty provides best surgical exposure and allows excision of sinus tract.

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

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. 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. 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%. 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.

Nasal dorsum reconstruction after pediatric nasal dermoid excision

BackgroundTo review our experience with pediatric nasal dermoids, and discuss reconstructive options for the nasal dorsum after pediatric nasal dermoid removal. MethodsRetrospective review of pediatric nasal dermoid cases from January 1 2005 through October 1 2016. ResultsTwenty-five cases (12 males, 13 females) were identified. Median age at time of surgery was 24 months (7–144). Ten nasal dermoids were superficial; eleven, intraosseous; one, intracranial extradural; three, intracranial intradural. Seven were located on the glabella; fifteen, dorsum; three, nasal tip. Twelve underwent vertical midline incision; ten underwent external rhinoplasty; and three combined approach with craniotomy. There was one recurrence four years postoperatively; which was secondarily resected completely via external rhinoplasty approach. Seven cases utilized endoscopic assistance. Conchal cartilage grafting was utilized in nine cases for dorsal reconstruction. A temporoparietal fascial graft was utilized to reconstruct the soft tissue defect in three patients. Median follow-up was 1.17 years (1 month-10 years). ConclusionsNasal dermoid is a rare congenital pathology. Recurrence rate is generally low provided that complete surgical excision is achieved. Achieving complete surgical excision means sometimes compromising the upper lateral cartilages and nasal bones. Conchal cartilage grafting is useful in reconstruction for lesions that significantly disrupt the nasal cartilages and/or nasal bones, wherein the defect is significant and osteotomies may not be sufficient. Temporoparietal fascia is a favorable adjunct for reconstructing soft tissue deficits when the skin is thin. Further studies and longer follow up are needed to adequately assess functional and cosmetic outcomes.

Quantifying Aerosolization of Facial Plastic Surgery Procedures in the COVID-19 Era: Safety and Particle Generation in Craniomaxillofacial Trauma and Rhinoplasty.

Background: COVID-19 poses a potentially significant infectious risk during procedures of the head and neck due to high viral loads in the nasal cavity and nasopharynx. Facial plastic surgery has significant exposure to these areas during craniomaxillofacial trauma procedures and rhinoplasty. Methods: Airborne particulate generation in the 1-10 μm range was quantified with an optical particle sizer in real time during cadaveric-simulated rhinoplasty and facial trauma conditions. Procedures tested included mandibular plate screw drilling, calvarial drilling, nasal bone osteotomy, nasal dorsal rasping, and piezoelectric saw use. Particulate generation was measured both adjacent to the surgical site and at surgeon mouth level (SML). Results: Mandibular plate screw drilling without irrigation generated significant particulate both adjacent to the surgical site and at SML (p < 0.01). Irrigation mitigated particulate generation at SML to nonsignificant levels. Calvarial drilling additionally produced substantial particulate above baseline adjacent to the surgical site (p < 0.01). Standard nasal osteotomies and dorsal rasping did not generate detectable airborne particulate, whereas piezoelectric saw use was associated with significant particulate generation both adjacent to the surgical site (p < 0.001) and at SML (p < 0.01). At SML, smaller particulate represented a significantly higher proportion of total particulate detected. Conclusions: The majority of craniomaxillofacial trauma procedures involve particle generation that may be limited in spread by the use of local irrigation. Most bony work involved in rhinoplasty can be safely performed without a high degree of particle formation. The use of piezoelectric instruments in rhinoplasty should be avoided when concerned for particulate generation.

Effectiveness of chondrofascial ‘cigar’ graft in contouring the nasal dorsum

Irregularities of the nasal dorsum after rhinoplasty are frustrating for the patient and the surgeon. Different grafts and implants have been adopted to camouflage this nasal imperfection. This study was performed to assess the outcome of a composite chondrofascial ‘cigar’ graft for contouring an irregular nasal dorsum. Thirty-six patients who underwent rhinoplasty between May 2014 and October 2016 were studied prospectively. The cartilaginous core of the graft was obtained from the septal or conchal cartilage, while the graft outer sleeve was harvested from the right lateral thigh fascia lata. The graft was secured over the nasal dorsum through an external rhinoplasty approach. The patients were followed up for at least 18 months postoperative. All participants were evaluated objectively by two independent rhinoplasty surgeons and subjectively by Rhinoplasty Outcome Evaluation (ROE) score. Donor site morbidity was also assessed. All patients had satisfactory aesthetic results with no apparent irregularities detected over the nasal dorsum. The ROE score improved, from a mean of 20.94±8.67 (range 8–58) preoperatively to a mean of 79.56±10.65 (range 50–96) postoperatively. Insignificant donor site morbidity was encountered, with inconsequential effects. The chondrofascial cigar graft is a reliable method for contouring dorsal irregularities, particularly in patients with thin nasal skin.

Contemporary Trends in the Surgical Management of Nasal Septal Perforations: A Community Survey.

There currently exists an overabundance of publications advocating different septal perforation repair methods. The objective of this article was to examine the preponderance of techniques and trends in the surgical management of septal perforations in the practices of otolaryngologists, rhinologists, and facial plastic surgeons. The study was designed as a multicenter cross-sectional survey. The participants were members of the American Academy of Facial Plastic and Reconstructive Surgery and the American Rhinologic Society. Septal perforation closure rates and perforation repair approach, technique, and interposition graft material preferences were the main outcomes. A total of 320 respondents completed the survey, of whom 75% performed perforation repairs. The success rates in closing perforations < 1 cm, 1-2 cm, and > 2 cm were 84%, 64%, and 31%, respectively. The respondents had a similar preference for the endoscopic (52%) and external rhinoplasty (49%) approaches, followed by the endonasal approach (43%). Bilateral intranasal mucosal advancement flaps (79%) and unilateral intranasal mucosal rotational or advancement flaps (60%) were the favored repair techniques. Most respondents (84%) incorporated an interposition graft and intranasal splints (89%) for the repair, and the most popular interposition graft material was acellular dermis (63%). The self-reported perforation closure success rates in this survey were lower than those published in the literature, a phenomenon possibly explained by the premise that surgeons with favorable outcomes are more apt to share their results. The preferred surgical approach was evenly distributed between the external rhinoplasty and endoscopic approaches and influenced by a surgeon's training, perforation size and location, and the need for concomitant rhinoplasty. This study is the first to characterize contemporary community trends in the surgical closure of septal perforations and demonstrates that while preference for perforation repair approach among the respondents varied, surgeons favored septal perforation repair using bilateral intranasal mucosal advancement flaps with an interposition graft.

Management of midline nasal dermoid lesions in children by external rhinoplasty.

ObjectivesNasal dermoid cysts are rare congenital lesions of ectodermal and mesodermal origin. Treatment of these cysts entails complete surgical excision, and several surgical incisions have been advocated. We present our experience utilizing an external rhinoplasty approach in seven children with nasal dermoid cysts and fistulae.MethodsA prospective study of 7 cases of nasal dermoid cysts and sinuses, diagnosed clinically and radiologically, were successfully treated by an external rhinoplasty approach in two teaching hospitals during the period of Apr 2011 to Nov 2013. Post operatively, an average follow-up of 12 months was observed by clinical examination, and the outcomes were documented and analysed.ResultsSeven children, 5 girls (71%) and 2 boys (29%), with ages ranging from 1.5 years to 16 years, who had nasal dermoid cysts and/or sinuses were successfully excised via an external rhinoplasty approach. The clinical presentation included midline facial swelling in five patients, a midline sinus in one patient and a dorsal midline nasal pit in one patient. No accessory tracts were found in these seven cases. Complete excision was achieved in 6 patients. There was one recurrence after 6 months with a successful complete resection with revision external rhinoplasty. All patients were followed up for an average of one year post operatively.ConclusionThe external rhinoplasty approach is an effective surgical approach in treating paediatric nasal dermoid cysts and sinuses with a very low incidence of recurrence.

Uses of Various Grafting Techniques in External Approach Rhinoplasty: An Overview.

The surgeons performing rhinoplasty found Graft selection the greatest challenge. To avoid an immune response the preferred choice thus far for nasal reconstruction would be autograft compared to allograft due to its lower rate of rejection. We have evaluated 30 patients who underwent open rhinoplasty and We used conchal and septal cartilaginous grafts in various forms by the open approach to correct various nasal deformities compared our experience regarding the operative technique, graft availability, indications, and limitations. No bony graft material or synthetic materials were used. Preoperative extensive evaluation of the patient was done in order to determine the type of deformity and the type of graft to be used in order to correct the deformity. Preoperative and postoperative photographs were taken in four basic views: frontal, lateral, lateral-oblique and basal in order to assess the results of the surgery. The study was done on 30 patients (20 male and 10 females) using the external rhinoplasty approach using the septal and conchal cartilages in different forms. Autologous septal cartilage was used in most of the patients (25 out of 30) and conchal cartilage was used in 5 patients. Multiple grafting techniques were used in some patients. Three patients had traumatic etiology. Columellar strut graft along with TIG technique was used in 16 patients, spreader graft was used in 8 patients, and septal extension graft was used in 5 patient and shield graft in 1 patient. Septorhinoplasty continues to evolve through various new techniques and modifications with the main goal to improve functional nasal airway and to restore cosmetic harmony to the face. Optimum result is very much dependent on the surgeon's attention to functional, aesthetic, and reconstructive principles and graft selection.

Combining polydioxanone plate, conchal cartilage interpositional graft and rotation flaps for repair of septal perforation

IntroductionNasal septal perforations repair, especially traumatic ones, is a very challenging subject. A lot of repair procedures had been described in the literature with variable success rates; but mostly not reaching as high as a 94% success rate. Aim of workCombining polydioxanone (PDS) plate, conchal cartilage interpositional graft and rotation flaps for repair of septal perforation; how I do it? Patients and methodsA prospective cohort study of eighteen patients who underwent repair of septal perforation using autologous conchal cartilage graft and PDS flexible plate with nasal mucosal rotational flap. ResultsComplete closure in 94.4%. ConclusionCombining conchal cartilage graft with PDS plate, through an external rhinoplasty approach, together with nasal floor mucosal flap covering this cartilage gives high success rates.

A New Era of Diced Cartilage Rhinoplasty: Our Experience.

The use of diced cartilage grafts in reconstructive surgery was first described by Peer in 1943 though it was not for rhinoplasty. A number of studies describing diced cartilage have followed since then, but the technique has never achieved widespread use. In recent years, however, an interest in using diced cartilage for augmentation rhinoplasty has resurfaced. As surgeons revisit this technique, it is important that this technique is subjected to critical evaluation in terms of materials, approaches, and indications of using using diced-cartilage augmentation. External rhinoplasty approach with diced cartilage as a graft was used to for augmenting the nasal dorsumin 32 patients. Cosmetic appearance improved in all cases both subjectively and objectively. Only one patient showed constriction of dorsum 09months after surgery. None of the patient had any intra-operative complication, 02 had donor site complication in the form of aural haematoma in 01 patient and wound infection in 01 patient. Diced cartilage technique is an attractive option for use in rhinoplasties especially those requiring augmentation procedures.

Update on primary cleft lip rhinoplasty

The optimal timing and techniques utilized to address the nasal deformity of the cleft lip continue to raise challenges and debate for the surgical community. There has been a shift in the paradigm addressing the nasal deformity to a more proactive approach. The goal of this article is to provide an update of the latest techniques for primary cleft rhinoplasty. A medical literature search was performed specifically targeting primary cleft rhinoplasty in order to review the current strategies implemented, including presurgical orthopedics, surgical incisions, reconstruction, and suture techniques. Today primary rhinoplasty is performed widely with many investigators reporting improved esthetic and functional outcomes. Both endonasal and external rhinoplasty approaches have been described for the unilateral and bilateral deformity. Goals include closure of the nasal floor and sill, symmetry of the alar base, and symmetry of the lower lateral cartilages with appropriate projection of the dome. Recent literature supports that rhinoplasty performed at the time of the primary cleft lip closure may reduce the frequency and magnitude of required intermediate and definitive rhinoplasty operations.

Precise Anatomical Study of Rhinoplasty

The prediction of nasal tip position in terms of projection, rotation, and length is a major challenge in rhinoplasty. Studies using preoperative and postoperative photographs lack accuracy owing to variable position, and computer-simulated models lack clinical applicability. (1) To describe an accurate and reproducible technique to study the effect of surgical manipulations on the nasal tip; and (2) to describe the effect on the nasal tip cartilages of the lateral crural steal (LCS). Cadaveric study in a tertiary hospital center using 10 cadaveric specimens. Heads were placed in a Mayfield head holder, and a 12.2-megapixel camera was fixed on a tripod in a perfectly still position and focused on the surgical field during all surgical manipulations. An external rhinoplasty approach was performed for all specimens, and a 4-mm LCS was achieved. Measures include tip projection, tip rotation, and nasal length using preoperative and postoperative photographs. Our method was successfully performed on all specimens: LCS resulted in a significant mean increase in projection using the Goode ratio (mean, 0.05; P = .005) and rotation (mean, 13.2°; P = .005). However, absolute tip projection variation was inconsistent, ranging from -1.0 mm to 0.6 mm. Nasal length was significantly shortened in all cases (mean, 1.3 mm, P = .005). We describe the first technique for precise anatomical study of tip position in rhinoplasty on cadaveric specimens. This technique was successfully applied to 10 consecutive nasal tips. We have shown a significant increase in projection using the Goode ratio and rotation with LCS. However, the effect on absolute projection is inconsistent. NA.

Surgical management of nasal alar rim and valve collapse

Introduction Nasal valve collapse can provoke sleep-related breathing disorders in adults. Congenital and acquired alar rim collapse necessitates surgical treatment. The purpose of the present communication is to share our experience with the procedures for reconstruction of the external nasal valve after septoplasty on the occasion of nasal septal deviation, reconstruction and rhinoplasty. Materials and methods During the period from 2000 till 2010, we treated 33 patients with bilateral alar rim collapse and 4 patients with unilateral one. Fifteen patients presented with a congenital pathology. Rhinoplasty was previously performed in 18 patients but septoplasty in four ones. There were nasal septum deformities in 32 patients. The following surgical techniques were applied: lateral rhinopexy, autologous cartilage transplantation, modified lateral rhinopexy, fixation of the cranial end of alar cartilage to the caudal end of triangular cartilages, and suturing techniques as well. In two cases, percutaneous fixation of the alar rims was carried out. Results The immediate postoperative results were satisfactory. A better aesthetics and an improved breathing function could be achieved in all the patients. The comparative evaluation of the surgical techniques identified the advantages of the external rhinoplasty approach, lateral rhinopexy, cartilage transplantation and suturing techniques. However, there patients complained of relapse two months after operation. Conclusion Based on our experience and the data from the world literature available the conclusion can be drawn that nasal valve and alar rim collapse represent a serious challenge for contemporary rhinosurgery. An individualized surgical approach to the single patients is obligatory. The aggressive surgical methods seem to be more effective. Acknowledgements P. Nedev M. Milkov R. Benchev D. Vicheva.

Unusual variants of midline nasal dermoid cysts: a series of three cases

Dermoids presenting in early life with a sinus tract along the midline of the nasal dorsum are well described. We present three very unusual variants of this condition. Case one was a two-year-old child with a pit in the philtrum of the lip. The tract pierced the nasal spine and extended towards the crista galli. Case two was a 15-month-old child with two separate sinus openings on the dorsum, one below and one above a dermoid cyst. Case three was a 17-year-old adolescent with neurological disability. Scanning showed a dermoid cyst deep in the anterior skull base, but the sinus tract had been obliterated by bony overgrowth due to long term use of antiepileptic medication. Cases one and two were successfully managed by complete excision via an external rhinoplasty approach. Case three, in contrast, was not operated upon due to bony obliteration of the sinus tract. Surgeons dealing with nasal dermoids must be able to adapt to the variable anatomical and clinical features of these lesions.

Repairing the Externally Crooked Nose: Are There Any Straight Answers?

Program Description: The crooked nose—and its aesthetic and functional issues—is a challenge frequently encountered by practicing otolaryngologists. Repair is not always straightforward and residual deformities can be distressing for the patient as well as the surgeon. With the prominence of the nose as a central defining feature of the face, any deviation is easily recognized since it detracts from overall facial symmetry. The purpose of this miniseminar, created by the Facial Plastic and Reconstructive Surgery Education Committee, is to shed light on the diagnostic and technical challenges of repairing the crooked nose. Panelists will focus on careful analysis of the anatomic factors responsible and highlight a repertoire of corrective surgical techniques. Discussion of the topic will be divided into the various thirds of the nose: the bony nasal vault, the cartilaginous mid-vault, and the nasal tip and caudal septum. Management strategies to be discussed include new osteotomy techniques, suture techniques, cartilage grafting, extracorporeal septoplasty, and tip-plasty. In contrast to the external rhinoplasty approach, the endonasal approach provides an alternative strategy—and perhaps a different philosophy—to addressing asymmetries of the nose. The role of endonasal rhinoplasty techniques will be presented. Whenever possible, literature will be referenced to support the discussion. The crooked nose is often caused by a complex interplay between bony and cartilaginous deformities, as well as scarring forces especially in traumatic and revision cases. Surgical strategies combine anatomic restoration with camouflage. A surgical plan requires not only an understanding of operative technique but also an understanding of the surgical expectations of the patient. Therefore, cases and patient scenarios will be presented by the moderator to the panelists (and the audience) for discussion. This miniseminar hopes to provide a nuanced understanding of rhinoplasty concepts and techniques that would be appreciated by seasoned surgeons and provide insight to the novice. Educational Objectives: 1) Recognize the various deformities and anatomic factors responsible for the crooked nose. 2) Learn to correct the bony nasal vault, cartilaginous mid-vault, and nasal tip and caudal septum. 3) Appreciate benefits and limitations of the external versus endonasal rhinoplasty approach to straighten the nose.