External Rhinoplasty Approach Research Articles

Transseptal Fracture Displacement Approach for Treatment of Pituitary Lesion

To the Editor .—The transseptal transsphenoidal approach for pituitary surgery, although an excellent route, produces the common rhinological complication, septal perforation. 1 Various authors have modified the technique to improve on exposure of the pituitary fossa, as well as to prevent cosmetic deformity, to avoid nasal septal perforation, to reduce operating time, and to facilitate technique. Some of the varied approaches that have been attempted are the external rhinoplasty approach, 2 the transseptal approach, 3 and the columellar flap technique. 4 However, in all of these techniques, septal perforation continues to pose a problem. Our technique is a modification of the endonasal transseptal approach, wherein septal perforation is avoided. Technique .—The patient is anesthetized, positioned, and draped. A Killian's incision is made on the left side after infiltration of the nasal septum. An anterior tunnel is made under the mucoperichondrium of the septal cartilage. As the dissection proceeds, the anterior

Nasal Reconstruction With Articulated Irradiated Rib Cartilage

Nasal structural reconstruction is a formidable task in cases where there is loss of support to both the nasal dorsum and tip. A multitude of surgical approaches and materials have been used for the correction of the saddle-nose deformity with varying degrees of success. Articulated irradiated rib cartilage inserted through an external rhinoplasty approach was used to reconstruct nasal deformities in 18 patients over a 6-year period. Simultaneous use of a midline forehead flap to reconstruct the overlying soft tissue was required in four cases. Follow-up ranged from 1 to 6 years (mean, 2.8 years). Results were rewarding in most cases with marked improvement in nasal support and airway. Revision and/or replacement secondary to trauma or warping of the graft was required in four cases. None of the patients exhibited infection, extrusion, or noticeable resorption. A description of the surgical technique, review of all the cases, and recommendation for continued use of this graft material are discussed.

Aesthetic structural nasal augmentation

This article addresses the author's preferred technique in the reconstruction of moderate and severe saddle nasal deformities. The prevailing concept is the provision of adequate structural support for the overlying nasal soft tissue coverage for an aesthetically pleasing outcome. All reconstructive efforts are undertaken via the external rhinoplasty approach. Detailed descriptions of the individual steps involved in the reconstructive sequence are included. Representative patient cases are included to demonstrate the versatility of techniques. This article addresses the author's preferred technique in the reconstruction of moderate and severe saddle nasal deformities. The prevailing concept is the provision of adequate structural support for the overlying nasal soft tissue coverage for an aesthetically pleasing outcome. All reconstructive efforts are undertaken via the external rhinoplasty approach. Detailed descriptions of the individual steps involved in the reconstructive sequence are included. Representative patient cases are included to demonstrate the versatility of techniques.

Septoplasty via the external rhinoplasty approach

Septoplasty via the external rhinoplasty approach

Complications of the external (combination) rhinoplasty approach

Complications of the external (combination) rhinoplasty approach

Dome Truncation for Management of the Overprojected Nasal Tip

The nasal tip highlights the facial profile, and in its most aesthetic configuration subtly projects anterior to the dorsum to create a soft supratip break. Overprojection of the tip in relation to the vertical facial plane and the nasal dorsum represents one variant of nasal-facial disproportion that can adversely affect an otherwise pleasant facial appearance. Several strategies for reducing either the lateral or the medial crus to deproject the tip have been suggested. This article describes a method of direct truncation of the dome using an external rhinoplasty approach that can reliably produce tip retrodisplacement while maintaining, or enhancing, tip rotation. Tip definition and projection are optimized by precise, direct reduction of the overprojected dome region and accurate sculpting and realignment of the remaining crural units. When the tip is retrodisplaced, alar flaring can occur; therefore, alar base reduction can substantially enhance the final outcome.

Developmental nasal anomalies

Despite the complex embryological development of the nose and surrounding structures, significant developmental nasal anomalies are rare. We therefore present our experience in the management of such anomalies (excluding choanal atresia) over the past 10 years. Fifty cases were surgically treated; two nasopharyngeal cysts, four hairy polyps, two meningoencephalocoeles, seven gliomata, 20 dermoids, two capillary haemangiomata, four fibromas, one fibromyxyoma, one mucocoele, one granuloma, one lipoma, two nasal aplasias, two nasal clefts and one nasal web. All cases presented with nasal obstruction and/or as a nasal mass. Computerized tomography and magnetic resonance imaging aided diagnosis determining the extent of intracranial involvement. Various surgical techniques were used ranging from simple excision to the lateral rhinotomy and Goodman's external rhinoplasty approach. Only five patients (10 per cent) suffered complications; two CSF leaks and three recurrences, all treated successfully.

Congenital Nasal Dermoid Cyst: Management Utilizing the External Rhinoplasty Approach

At the recent meeting of the Fifth International Symposium of the American Academy of Facial Plastic Reconstructive Surgery, Toronto, Canada, Raymond J. Konior, MD, Houston, Tex, reviewed the causes and concerns that facial plastic surgeons should consider when approaching nasal dermoids; namely, that one should establish whether it communicates with the cranial cavity. Konior emphasized that lesions should be approached soon after diagnosis, early in life. He pointed out that the external rhinoplasty approach is a logical approach to this problem, with few disadvantages and many advantages, including excellent exposure and flexibility for accomplishing other required nasal procedures such as osteotomies and direct reconstruction.

External rhinoplasty in the tropics.

The thick oily and pigmented skin present in majority of tropical patients makes rhinoplasty challenging surgery. Rhinoplasty by the external approach though gaining increasing acceptance all over the world is yet to gain popularity in this country. Hypertrophied scars are not uncommon in coloured skin and the reluctance to give an external incision for a cosmetic procedure is natural. We started the external rhinoplasty approach with some reservations, however in a series of over seventy cases, no significant problem has been encountered, with the columellar scar. Accurate approximation of the columellar wound is probably a more important factor in wound healing than the skin colour. Our experience of external rhinoplasty is presented.

Advances in nasal tip surgery. The lateral crural steal.

Increasing nasal tip projection, rotation, and definition have classically been attempted through a variety of lobular cartilage incising or excising techniques. Resultant long-term complications, including bossing, alar notching, pinched tips, and alar collapse, have occasionally resulted from the use of these techniques. The majority of these complications have arisen secondary to a loss of structural support following the interruption of the lower lateral cartilages. This article describes the "lateral crural steal," a method of increasing nasal tip projection and nasal tip rotation while preserving the integrity of the lobular cartilage complex. The procedure uses the external rhinoplasty approach for exposure. By elevating both the dorsal and the vestibular skin from the domes of the lobular cartilages, the lateral crura may be advanced onto the medial crura to further project the nasal tip and to reorient the tip upward. This technique along with its philosophy and long-term follow-up results are presented.

Trends in Rhinoplasty

The external rhinoplasty approach continues to stimulate both the development of new ways to sculpture the nasal tip and thoughtful reevaluation of older ones. The open technique encourages careful study of tip anatomy and allows precise and direct manipulation of the lower lateral cartilages. Though still preferred by most surgeons only in a select number of cases, the external rhinoplasty has encouraged a trend toward more repositioning and augmentation of the nasal tip framework. Part of this trend is a renewed interest in the vertical division of the alar domes and the prototype of this technique first described by Dr Irving Goldman over 30 years ago. In theArchives, Dr Goldman detailed his approach to the mesial crura in nasal tip reconstruction as follows: Circumferential incisions are made within the lower margins of the nostrils, extending caudally and downward and including the posterior part of the columella for about one

Surgery of the Cleft Nose

A thorough review of basic concepts of surgery of the cleft nose was presented by Robert Bumsted, MD, at the spring scientific meeting of the American Academy of Facial Plastic and Reconstructive Surgery in Denver. The author reviewed a series of 200 cases that occurred over a ten-year period. He performed maneuvers to enhance columellar length and to reposition the alar base at the time of the primary cleft lip repair at approximately 10 weeks of age. Alar base implants of irradiated autogenous cartilage are inserted intraorally with extreme overcorrection of the alar base support. Septoplasty and turbinate resection surgery are performed at the age they become necessary for maintenance of adequate nasal airway. The ultimate rhinoplasty repair work during the teenage years is performed through an external rhinoplasty approach with total freeing of the lateral crura from vestibular skin and an asymmetrical V-to-Y columellar lengthening procedure. The overall surgical

The Anatomy of External Rhinoplasty

The results achieved in rhinoplasty are directly related to the surgeon's ability to elucidate how subtle changes in the bony and cartilaginous supports of the nose will alter its appearance. Therefore, any surgeon who performs rhinoplastic procedures requires a sophisticated knowledge and understanding of the anatomy of the nose. This article reviews the anatomy of the nose from the perspective of the external rhinoplasty approach.

External Rhinoplasty Approach for Malignant Tumors of the Anterior Nasal Septum

Malignant tumors arising from the nasal septum are rare. The predominant tumors include squamous cell carcinoma, adenocarcinoma, and malignant melanoma. The majority of these lesions are seen on the anterior portion of the septum. The recommended treatment for septal malignancies is wide excision usually approached via a lateral rhinotomy. However, this procedure may have increased morbidity and a less than desirable cosmetic result. We feel that the external rhinoplasty approach for tumors of the anterior nasal septum offers the surgeon excellent visualization, decreased morbidity, and superior cosmetic results. We present a case of squamous cell carcinoma of the anterior nasal septum involving the columella that was successfully managed using this approach.

Complications of External Rhinoplasty-Reply

In Reply.—We thank Jack R. Anderson, MD, for his letter. The concepts expressed are extremely important. However, two very disturbing associations are implied. First, Dr Anderson has associated the photographs in our article with a declaration of inept surgery. This equation is obviously seriously flawed. Second, the ideal is mistaken for the real. Ideally, sequelae should not occur with attentive and informed supervision. Realistically, sequelae do occur even with attentive and informed supervision. Dr Anderson's words ... it is hard to see... are certainly reflective of his circumstances. This is the reason we, rather than he, wrote the article. After he has performed more than 2000 open rhinoplasties, it may be difficult to see the sequelae of initial experiences. We have publicly encouraged the acceptance and use of the external (combined) rhinoplasty approach since 1980. Our experience with it goes back nine years. Still, we ask your readers to note our

Complications of the external (combination) rhinoplasty approach.

More rhinoplastic surgeons are using the external (combination) rhinoplasty approach for selected patients. Although several large series report few complications, the initial experience of newcomers may be different. A series of 26 external rhinoplasty approaches was examined, representing the initial experience of supervised residents. The most common complication was incising the anterior margin of the lower lateral cartilage at the juncture of the lateral and medial crura. To prevent this problem, it is recommended that the skin be elevated off the lower lateral cartilages from both a medial direction up over the domes and a lateral direction downward. To repair this complication, a figure-of-eight suture is used to reapproximate the incision.

External rhinoplasty approach to transsphenoidal hypophysectomy.

The history of transsphenoidal hypophysectomy demonstrates the soundness of the basic concept of approaching the sella turcica in a midline fashion through the nose. Conceptually, it has not been eclipsed since first evolved by Cushing in the early part of this century. The surgical advances since Cushing's time have been major refinements in instrumentation and minor refinements of his basic technique. The external rhinoplasty approach is such a refinement. We have used this technique in a two-year period between June 1982 and June 1984 on 14 patients. We have found this technique for transsphenoidal hypophysectomy to be a simple, reliable, rapid technique for exposing the septum and the floor of the nose. It provides excellent exposure to the sphenoid sinus and pituitary gland without loss of nasal tip projection or other cosmetic deformity.

Extended Applications of the External Rhinoplasty Approach

Extended Applications of the External Rhinoplasty Approach

External rhinoplasty

The external rhinoplasty approach extends the usual marginal nasal incisions to include a notched transcolumellar incision. This maneuver enhances surgical exposure for the analysis and correction of all types of nasal bone, nasal septum and nasal cartilage deformities. Nasal septal perforation, nasal bone grafting and hypophysectomy my be operated upon through this excellent avenue of exposure.