Nasal Base Research Articles

Rare fractures of the maxilla: the isolated fracture of the anterior nasal spine and of the posterior wall of the maxillary sinus

There are exceptional fractures of the maxilla that have not been described in the literature. They are characterised by their proper mechanism and particular circumstances related to the anatomic conditions. These fractures ought to be described to define novel clinical features. Fracture of the nasal spine needs to happen a direct choc on the nasal base with an anatomically long spine. Clinical presentation showed important oedema of the upper lip, ecchymosis and a swelling of the superior vestibular sulcus. The diagnosis is confirmed by means of an X-ray revealing the fracture on the profile incidence. Isolated fracture of the posterior wall of the maxillary sinus is another rare entity created by a direct choc on the maxillary tuberosity. We advocate as a possible hypothesis that direct trauma of this region causes intrasinus high pressure leading to the fracture of the posterior wall. The authors tend to describe these rare fractures and to establish their anatomic and clinical aspects.

Nasal Base Retraction: A Treatment Algorithm.

Nasal base retraction results from cephalic malposition of the alar base in the vertical plane, which causes disharmony of the alar base with the rest of the nose structures. Correcting nasal base retraction is very important for improved aesthetic outcomes; however, there is a limited body of literature about this deformity and its treatment. Create a nasal base retraction treatment algorithm based on a severity classification system. This is a retrospective case review study of 53 patients who underwent rhinoplasty with correction of alar base retraction by the senior author (S.T.). The minimum follow-up time was 6 months. Levator labii alaque nasi muscle dissection or alar base release with or without a rim graft on the effected side were performed based on the severity of the alar base retraction. Aesthetic results were assessed with objective grading of preoperative and postoperative patient photographs by two independent plastic surgeons. Functional improvement was assessed with patient self-evaluations of nasal patency. Also, a rhinoplasty outcomes evaluation (ROE) questionnaire was distributed to patients. Comparison of preoperative and postoperative photographs demonstrated that nasal base asymmetry was significantly improved in all cases, and 85% of the patients had complete symmetry. Nasal obstruction was also significantly reduced after surgery (P < 0.001). The majority of patients reported satisfaction (92.5%), with an ROE total score greater than or equal to 20. New techniques and a treatment algorithm for correcting nasal base retraction deformities that will help rhinoplasty surgeons obtain aesthetically and functionally pleasing outcomes for patients.

Patient Characteristics and Frequent Localizations of Rhinoliths

A rhinolith is a rare entity affecting all people in all age groups. It is defined as a mineralized foreign body. The purpose of the present study was to reveal the distribution in age and gender and the localization, side, and prominent symptoms of rhinoliths to identify the risk groups and characteristics of the rhinoliths in a large case series. A retrospective review was performed from the medical charts of 28 patients who were diagnosed with rhinolith and underwent surgery between May 2011 and January 2015 in Ankara Research and Training Hospital. All data, including age, gender, duration of symptoms, localization of the lesion and accompanying pathologies, were documented. In total, 28 patients (18 females and 10 males) with a mean age of 26.2±16.6 (5-62) years who were diagnosed with rhinolithiasis were reviewed. Nasal obstruction (71.4%) and nasal discharge (64.3%) were the most common complaints. The rhinolith was located in the right nasal cavity in 24 patients and in the left in four; this difference was statistically significant (p<0.001). There were 11 accompanying pathologies including nasal septal deviation (n=6), nasal polyposis (n=2), concha bullosa (n=2), and adenoid vegetation (n=1). In 21 (75%) patients, the most common site was the nasal base of the cavity between the inferior turbinate and the nasal septum. If unilateral right-sided nasal obstruction with foul-smelling purulent discharge is detected in a young adult and a nasal examination reveals a mass in the floor of the cavity, a rhinolith should be strongly considered in the differential diagnosis.

Outcome of double-cut correction on secondary deformity after unilateral cleft lip repair with nasolabial muscle reconstruction

Objective To investigate the surgical methods and effect of double-cut nasolabial muscle directional three-dimensional reconstruction on the secondary deformity of unilateral cleft lip repair. Methods We first increased a contralateral vermilion secondary incision based on the nasolabial muscle directional three-dimensional reconstruction, without damaging the contralateral white lip skin, via suturing both sides of nose wings bundle of nose outside corner under the columella muscle, and overlapping suturing both sides of the orbicularis muscle flap, and then rebuilt and took shape of the nest and the crest. Results All incisions healed well in 18 patients, all nasal deformities were corrected better than the traditional methods, with the nasal base plump, the nasal sill formed close to the contralateral side, and rebuild the philtrumdimple and philtrum crest, with clear appearance and symmetrical form. A good appearance was obtained on the both sides of nostril, nasal base and the nasal sill, and the effect of preoperative design achieved. Conclusions Both sides of the nostrils size, nasal sill and shape are almost perfectly symmetrical, and the double-cut nasolabial muscle directional three-dimensional reconstruction is suitable for repairing the secondary deformity after unilateral cleft lip repair. Key words: Secondary deformity; Cleft lip; Nasal deformity; Repair

Follow up of surgically-assisted rapid maxillary expansion after 6.5 years: skeletal and dental effects

Surgically-assisted rapid maxillary expansion (SARME) is a technique used to widen the maxilla, and we present the results of our long-term follow up (6.5 years). Seventeen patients who had been treated with SARME and prospectively followed were invited for long-term follow up using dental casts and posteroanterior cephalograms. The following measurements were made on the dental casts: transverse distances at canine, premolar, and molar level, length of the arch, and width and depth of the palate at premolar and molar level. The distance between the left and right nasal bases and the widening of the inferior maxilla were measured on the posteroanterior cephalograms. Boneborne and toothborne distractors were used in 8 and 9 patients, respectively. In the study of dental casts, there was a significant increase in transverse width in the canine (P<0.001), premolar (P<0.001) and molar (P=0,001) and these remained stable in the long term. The arch length did not increase significantly, but the palatal width increased significantly in the premolar (P<0.001) and molar (P=0.001) regions. No effect was seen in palatal depth. On the posteroanterior cephalograms the width of the inferior part of the maxilla was increased, but not significantly so. There were no significant changes at the nasal base. We conclude that SARME is a predictable technique to widen the maxilla in the long term.

Aesthetic Outcomes of Alar Base Resection in Asian Patients Undergoing Rhinoplasty

Combined sill and alar excision is a useful procedure for correcting a wide nasal base and flared alar lobules. However, the aesthetic outcomes of this technique remain poorly reported. To evaluate the aesthetic outcomes of combined sill and alar excision in Asian patients undergoing rhinoplasty. A retrospective cohort study of 73 consecutive patients who underwent combined sill and alar excision from March 1, 2004, to January 31, 2013, was conducted at a tertiary referral hospital in Korea. Combined sill and alar excision. Changes in the ratio of the interalar distance to intercanthal distance and frequencies of alar flaring, nostril symmetry, and nostril shape, as measured by reviewing photographs taken before and after the surgery. Among the 73 patients (50 men and 23 women; mean [SD] age, 36.5 [12.3] years) the mean (SD) ratio of interalar distance to intercanthal distance changed significantly from 1.07 (0.11) to 1.04 (0.08) (P < .001). Of the 60 patients with alar flaring, 45 (75%) no longer had flaring after the procedure. The frequency of nostril symmetry increased from 38 patients (52%) to 46 (63%) (P < .001). The frequency of horizontally shaped nostrils decreased from 21 patients (29%) to 2 (3%), while the frequency of the preferred pear-shaped nostrils increased from 20 patients (27%) to 35 (48%) (odds ratio, 1.16; 95% CI, 0.63-2.14; P = .02). There were 4 cases of complications, namely, alar deformity (1 patient [1%]), unsatisfactory correction of asymmetrical nostrils (1 [1%]), and unsatisfactory correction of alar flaring (2 [3%]). Combined sill and alar excision was a useful technique with a low complication rate for correcting wide alar base, alar flaring, nostril asymmetry, and nostril shape. 4.

Soft, hard-tissues and pharyngeal airway volume changes following maxillomandibular transverse osteodistraction: Computed tomography and three-dimensional laser scanner evaluation.

Maxillomandibular transverse osteodistraction (MMTOD) is an alternative approach to the traditional treatment for transverse maxillary and mandibular deficiencies and crowding. The aim was to report soft and hard-tissues changes and airway volume variation. In this study, skeletally mature, non-syndromic patients with transverse maxillary and mandibular hypoplasia, who underwent a MMTOD between 2010 and 2012, were included. Surgical changes were analysed using clinical evaluation, three-dimensional facial surface data and computed tomography analysis before (T0) and after the completion of post-op orthodontic treatment (T1). Nineteen patients (eight males and eleven females; average age: 26.3 years) were enrolled. MMTOD produces facial changes in the cheek, paranasal areas, nasal base and chin. Facial changes are mostly explained by the underlying skeletal movements, which are essentially represented by the transverse enlargement of both the maxilla and the mandible. Following MMTOD, the airway volume and the lateral dimension of the cross-sectional airway increased significantly. MMTOD is a technique that allows an increase in airway volume and in both maxillary and mandibular arch perimeters simultaneously by increasing skeletal width. Facial appearance is improved and a stable occlusion is obtained.

“The magic finger technique” a simplified approach for more symmetric results in alar base resection

Alar base surgery is one of the most important and challenging steps of aesthetic rhinoplasty. While an ideally shaped alar base is the goal in a desired nose, nearly all patients have asymmetric nostrils preoperatively. Ethnicity, trauma, cocaine use, or previous rhinoplasties are some factors affecting the width and shape of the nasal base. After the conclusion of all planned rhinoplasty sequences and closure of the mid-columellarincision, we mark the midline inferior to the columella at the nasolabial junction and use acaliper to measure an equal distance from the mid-columellar point to the alar creases on eachside, and mark the medial points of the alar creases. Next we draw on the natural creasesbilaterally extending to 3 o’clock on the right side and 9 o‘clock on the left side as the limit ofthe lateral excisions to avoid scarring. We then gently depress the alae and alar-facial grooveswith the index finger and allow the formation of new creases superior to the original alarcreases in order to detect excess skin to remove. After marking, the resection was performed with a no. 15 blade. The excision was closed using 6-0 Prolene sutures. We aimed to describe a simple technique for making asymmetric resections in which theapplication of pressure by a finger reveals excess skin in both nostril sill and nostril flareindependently for each alar base. With these asymmetric excisions from the right and left alar bases, a more symmetric nostrils and nasal base can be achieved. Level of Evidence: Level IV, therapeutic study.

Efficacy of the nasal molding in patients with unilateral cleft lip and palate in newborn to 6-month-old patients

Objective: The aims of this research were to assess and describe the clinical changes in the nostril that shows depression and asymmetry in patients with unilateral cleft lip and palate (UCLP) treated with presurgical nasoalveolar molding (PNAM) in the Center of Medical Specialties of the State of Veracruz (CEMEV). Material and methods: An observational, descriptive, longitudinal and prospectivecohort study was carried out. 15 patients with ages between0 and 6 months were part of the study. Measurements of t nostril height, nostril width, nasal basal width and columella length were performed at three times (T1, T2 and T3). Results: The vertical, horizontal and nostril base lengths showed a signifi cant decrease in the initial measurement (T1), presenting a close similarity with the healthy nostril, with only 0.8 mm of difference with the healthy nostril in the vertical dimension (p ≤ 0.000982 t Wilcoxon); in a horizontaldimension, 5.02 mm (p ≤ 0.000023 t Student) and comparedwith the measurements of the nasal base it was found that at T3 it decreased 51%, (p ≤ 0.00004 t Student). This refl ects the effectiveness of the nasal molding treatment for correcting the nasal asymmetry caused by a nasal, lip and alveolar cleft. Conclusion: Treatment with the PNAM is effective since it reduced by 50% at least nasal depression, compared with the initial and fi nal measurements.

Correcting the Alar Base Retraction in Crooked Nose by Dissection of Levator Alaque Nasi Muscle

Nasal base retraction results from cephalic malposition of the alar base in the vertical plane causing disharmonies in the alar base. In literature, there are some excisional procedures to correct this deformity, but it may result to nostril distortion, stenosis, or upper lip elevation. Here, a new technique is reported for the correction of nasal base retraction in crooked nose by manipulating the levator labii alaeque nasi muscle. Sixteen patients, 6 women and 10 men ranging in age from 21 to 42 years, who have alar retraction with crooked nose, were operated, with a follow-up period of 12 months. Preoperative and postoperative frontal, profile, base, and oblique base views in a standard manner were taken and analyzed with Image software. Comparison of preoperative and postoperative photographs demonstrated that nasal base retractions were corrected in all cases without distortion and recurrence. Nasal obstruction was reduced after surgery, and self-evaluation of nasal patency scores significantly increased in all patients (P < 0.001). Functional and aesthetic outcomes were satisfactory for surgeons and the patients. Careful analysis to identify the deformity and proper selection of the technique will ensure a pleasing outcome. The new techniques presented for the correction of nasal base retraction and prevention of the recurrence of the dorsal deviation will help rhinoplasty surgeons obtain pleasing outcomes.

Medially based de-epithelialized flap for nasal base narrowing and nostril sill augmentation in a cleft lip nasal deformity

Aim: The authors observed the nostril floor in a gross cadaver specimen histologically and innovated a medially based de-epithelialized flap for nasal base narrowing and nostril sill augmentation.

Primary Open Rhinoplasty.

Rhinoplasty is perhaps the most complex cosmetic surgery procedure performed today. It is characterized by an intricate interplay between form and function, with patient satisfaction being dependent not only on improvement of nasal appearance but also resolution of preexisting airway symptoms. The prerequisite for successful execution of this challenging procedure is a thorough understanding of nasal anatomy and physiology. Hence, a thorough preoperative evaluation is at least as important and the surgical skill in performing the operation. Establishing an accurate diagnosis through a comprehensive nasal analysis is obligatory. As to the surgical approach, much has been written about the advantages and disadvantages of closed vs open rhinoplasty. The more commonly chosen open approach has numerous advantages, including improved visualization without distortion, thus, enabling precise diagnosis and correction of deformities. While the surgical treatment of existing nasal deformities is tailored to the needs of the individual patient, the authors have noted a total of 10 essential components to form the foundation for successful technical execution of rhinoplasty. These include: (1) septoturbinotomy; (2) opening the nose; (3) humpectomy/spreader flaps; (4) tip-plasty; (5) supratip-plasty; (6) columellar strut; (7) dorsal augmentation; (8) nasal base reduction; (9) osteotomies; and (10) rim grafts. Postoperative, a variety of problems, such as edema, may be successfully addressed without surgical intervention. Diligent postoperative management is critical in ensuring a positive patient experience. Finally, a comprehensive understanding of possible postoperative complications, such as bleeding, ecchymosis, edema, and persistent or new iatrogenic deformity is mandatory prior to offering rhinoplasty to patients.

Assessment of nasal base morphology using new proportion indices in Chinese.

ObjectiveThe aim of this study was to measure the soft tissue of the external nasal base in Han Chinese women and identify indices with which to simplify morphological assessment.MethodsThis study involved 155 Han women in China. The control group comprised 101 women, and the surgical group comprised 54 women. Using measurements and analytical software, we measured the nasal base on photographs in the two groups. The nasal base was also measured preoperatively and postoperatively in the surgical group. Results from the two groups were compared with a t test.ResultsThe proportion index of the nasal tip triangle (upper nasal base) was c-prn/a = 0.33 ± 0.05 ≈ 1:3. The proportion index of the nostril trapezoidal (lower nasal base) was c-sn/all-alr = 0.25 ± 0.04 ≈ 1:4. The proportion indices of the nasal tip triangle and the nostril trapezoidal were larger in the postoperative surgical group than in the control group. Therefore, the nasal base morphology became stereoscopic through surgical correction.ConclusionThe current study provides a credible and objective reference for cosmetic nasal surgery. The proportion indices related to the nasal base can be used to intuitively and vividly ascertain the nasal base morphology.Level of evidenceIII.

The Tongue-in-Groove Technique in Primary and Revision Rhinoplasty.

The tongue-in-groove (TIG) is a conservative but powerful surgical suture technique to control tip rotation and projection, to set an appropriate alar-columellar relationship, to straighten a caudal septal deviation, and to stabilize the nasal base. TIG is suitable in primary and most revision cases and is easily combined with other surgical techniques. Seventeen years after its popularization, the TIG technique is embedded in modern-day rhinoplasty literature and teaching material. This article describes indications and considerations during external primary and revision rhinoplasty, based on clinical experience and the available literature.

Columellar Aesthetics in Open Rhinoplasty.

Detailed descriptions of the ideals of columellar aesthetics and nostril shape are conspicuously lacking from the medical literature. Achieving an aesthetic nasal base is critical to an optimal rhinoplasty result. Deviations in the columella and variations in its width and height lead to distortion of nostril shape and frequently compromise function. Six types of columellar disproportion are presented with detailed explanations of how to treat each. By properly recognizing and addressing columellar deformities, the surgeon can optimize both the aesthetic and functional results that are achieved.

Preservation of nostril morphology in nasal base reduction.

Asian patients often desire reduction of the base and alar lobules of the Asian mesorrhine nose. Sill excision is commonly used, but may result in an angular or notched nostril rim. We developed an internal method of alar base reduction involving triangle flaps for sill resection. This method avoids alar rim notching and teardrop deformity. Cinching sutures and double-layer closure avoid tension on the wound. We categorized the results in 50 patients (4 men, 46 women) who underwent surgery between November 2012 and August 2015 and who could be followed up for more than 3months. The mean age of the subjects was 26.3years and the mean follow-up period was 8.9months. Forty patients underwent base reduction with the internal method, while ten with alar flare were treated with additional external resection. The mean reduction of the nostril sill width was 4.8mm for both methods. In the subjects receiving flare resection, the mean reduction of the lateral alar width was 4.4mm. There was no notching at the suture site. Complications included a short scar running obliquely under the sill in 13 patients and a trap door deformity in one patient. Nasal base reduction is widely performed, but subject to outcomes with abnormal nostril contour. We used triangle flaps to narrow the sill, and cinching sutures to prevent tension on the wound. Our methods prevent nostril notching and/or teardrop deformity. Scarring can occur, but can be reduced using cinching sutures for wound relaxation. 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.

Modified alar base cinch suture fixation at the bilateral lower border of the piriform rim after a maxillary Le Fort I osteotomy

Classic cinch suture narrowing of the nasal alar base by medially suturing the bilateral nasolabial soft tissue with one long suture has a limited effect. The modified cinch method described in the present study anchors non-absorbable sutures to the bilateral lower border of the piriform rim and provides optimal direction, position, and stability. The sutures can be shortened and the strength kept stable while the surgical wounds heal. Separate bilateral sutures can also reduce interference and distortion from nasotracheal intubation and make the nasolabial profile more symmetrical. Seventeen consecutive cases of maxillary Le Fort I osteotomy were analyzed. The nasal and alar base width changes were 0.4±1.2mm and 0.1±1.1mm, respectively, and the widening rate was only 1.1%. Compared with the results of other studies, postoperative nasal flaring was well controlled using the modified cinch suture anchored to the bilateral lower border of the piriform rim described in this study.

Digital Imaging in Secondary Rhinoplasty.

Rhinoplasty remains one of the most commonly performed operations in plastic surgery. Little is known regarding the use of imaging in secondary rhinoplasty. Secondary rhinoplasty is a far more complex operation than primary rhinoplasty. The objective of this study was to assess the role of software imaging in patients undergoing secondary rhinoplasty. A retrospective review was performed to identify patients undergoing secondary rhinoplasty performed by the senior author (R.J.R.) from January of 2000 to August of 2013. Forty consecutive patients met inclusion criteria. The degree of improvement was graded in comparison with both the preoperative photographs and software imaging using a graded scale. A total of 40 patients met inclusion criteria. There were 35 women (87.5 percent) and five men (12.5 percent). The nasal dorsum was found to have an average rating of 2.36 between the two observers, the midvault had an average rating of 2.65, the nasal tip had an average rating of 2.27, the nasal alae had an average rating of 2.63, and the nasal base had an average score of 2.99 CONCLUSIONS:: Based on the results of this study, the authors have determined that preoperative digital imaging can provide a reasonable expectation for patients undergoing secondary rhinoplasty. However, digital imaging must be used with caution, as secondary rhinoplasty patients have heightened expectations and unknown anatomy from their previous operation. The nasal tip and dorsum are especially difficult to adequately predict, and this should be discussed with the patient before surgery. Therapeutic, IV.

Osteoectomy in Rhinoplasty: A New Concept in Nasal Bones Repositioning.

Modern techniques of osteotomy have evolved to take into account the effects of bony repositioning on functional as well as aesthetic outcomes. Although a variety of methods have been described to appropriately mobilize and reposition the bony nasal vault, there is still no single procedure that can successfully manage nasal bones in its entirety. We present the bone chisel scraping osteoectomy technique for lateral and medial osteotomies with the aim of managing nasal bone deformities that can overcome diverse shortcomings of the conventional methods. The new operative method was performed in 184 nasal bone osteoectomies (92 patients, 22 men and 70 women), ranging in age from 18 to 69 years (mean age, 38 years). The functional results were evaluated postoperatively by the Nasal Obstruction Symptom Evaluation scale, a brief and easy to complete validated questionnaire with a final score grading from 0 to 100 at 3 and 6 months postoperatively. With this new approach, no functional problems were reported. The mean Nasal Obstruction Symptom Evaluation scale score was 5.3 at 3 months and 1.9 at 6 months. Only 1 primary case was reoperated for open roof deformity. Comparing the results with the previous osteotomy series of the senior author osteoectomy and osteotomy revision rates for inadequate bone mobilization were similar but osteoectomy technique did not create functional problems as the osteotomy technique did. Although this technique prolongs the operating time, it could offer considerable advantages in comparison with the classical techniques using osteotomies and hammer. This is because it offers a greater respect to the nasal respiratory function and gives a much better nasal base width control, resulting in more predictable results, less trauma, and therefore a lower risk of postoperative complications.

Upward Advancement of the Nasolabial Components at Unilateral Cleft Lip Repair Prevents Postoperative Long Lip.

To prevent the occurrence of postoperative long lip, longitudinal postoperative changes in nasolabial forms of patients with unilateral cleft lip who underwent primary lip repair with or without upward advancement of the nasolabial components were compared. Forty-three subjects (24 unilateral cleft lip and palate [UCLP] and 19 unilateral cleft lip solely, and cleft lip and alveolus [UCL/UCLA]) who underwent primary lip repair with upward advancement of the nasolabial components (NA group) and 30 subjects (16 UCLP and 14 UCL/UCLA) without upward advancement (LA group) were enrolled. Postoperative photos taken at 1 and 6 months and at 1, 2, and 3 years were used for measuring the heights of the nasal alar base (NBH), the columellar base (CBH), Cupid's peak (CPH), and the upper lip (ULH). The ratios of these measurements between the affected and unaffected sides were calculated in both groups. In the LA group, the 3-year postoperative all-items ratios of UCLP were significantly larger than those at 1 month postoperatively, demonstrating drooping of the nasolabial tissues in the affected side (all P < .01). Furthermore, the 3-year postoperative CPH and ULH ratio of UCL/UCLA was significantly larger than that at 1 month postoperatively, demonstrating the long lip (P < .01). In the NA group, the NBH, CBH, and CPH ratios of both UCLP and UCL/UCLA did not show significant differences between 1 month and 3 years postoperatively. Upward advancement of the nasolabial components prevents postoperative long lip.