Nasal Base Research Articles

Lengthening the nose with a tongue-and-groove technique.

Lengthening the short nose is often a major task. The ability to maintain proper alignment between the nasal base and dorsum may prove difficult without sacrificing the suppleness of the former. In this article, the authors introduce a technique of nose lengthening that ensures alignment of the tip with the rest of the nose yet avoids tip rigidity, unless a significant increase in tip projection is also planned. Two spreader grafts are placed, one on either side of the septum, and are extended beyond the caudal septal angle proportional to the planned nasal lengthening. A columella strut, with the cephalocaudal dimension equaling the combination of the width of the existing medial crura plus the amount of planned nasal lengthening, is placed between the medial crura in continuity with the caudal septum and is fixed to the medial crura using 5-0 clear nylon or polydioxanone suture. If additional projection beyond what is achievable by mere placement of a columella strut is required, the strut is fixed to the spreader grafts in a more projected position. Otherwise, the columella strut is simply positioned between the extensions of the spreader grafts. It is necessary to mobilize the lower lateral cartilages to prevent excessive columella show. This procedure has been performed on 23 patients over the past 12.5 years, with 20 patients enjoying good-to-excellent results. The advantages of this technique include its predictability and reproducibility, and the ability to elongate the nose with a mobile nasal base that is in line with the rest of the nose. If suture fixation is used to gain more projection, the technique proves dependable but the nose will become more rigid than is optimal. The requirement of three pieces of properly shaped septal cartilage, which might not be available when a secondary rhinoplasty is performed, is the major disadvantage of this operation. Furthermore, the procedure is, to some degree, labor-intensive.

Morphometry of nasal bases and nostrils in koreans

To investigate morphological characteristics of Korean noses, nasal bases and nostrils were measured and classified in Korean adults. The height and the width of the nasal base, the height and the width of the columella, the length of the long and short nostril axes, and nasal alar angle were measured. The shapes of the nostrils were classified into 7 types by the angle between the right and left long axes of the nostrils. Each measurement was compared with other studies.

MAXILLARY SINUS SCHWANNOMA EXTENDING TO ORBIT

ABSTRACTSchwannoma occur in the head and neck region more frequently than in any other part of the body, affectingmainly the eighth cranial nerve. However schwannoma in the nasal cavity and paranasal sinuses is a rareentity with only sporadic cases appearing in the literature. We present one such rare case of maxillarysinus schwannoma extending to nasal cavity orbit and anterior skull base in a 46 year old male. The tumorwas successfully removed by midfacial degloving approach. The relevant literature on the presentation,radiology and management of schwannoma of maxillary sinus is discussed.Key Words: Schwannoma, Maxillary Sinus, Nasal Cavity.

Analysis of the African American female nose.

The African American nose has been broadly classified as ethnic yet it differs significantly in morphology from that of other ethnic groups with which it is categorized. The objectives of this study were to (1) establish an objective protocol for analysis of the African American female nose using anthropometric measurements, and (2) determine whether subjective subcategorization schemes are a reliable replacement for anthropometry. African American women (n = 107) between the ages of 18 and 30 years consented to participate in this study. Photographs and 14 standard anthropometric measurements were taken of the face and nasal region, including nose length, nose width, special upper face height, intercanthal distance, mouth width, nasal bridge inclination, nasal tip protrusion, ala thickness, nasal root width, nasal bridge length, tangential length of ala, length of columella, nasofrontal angle, and nasolabial angle. Nasal indices including nose width-nose height index, nasal tip protrusion-nose height index, and nasal tip protrusion-nasal width index were calculated. In addition, photographic analysis was performed to evaluate nostril shape, nasal base shape, and nasal dorsal height. Proportional relationships and subcategorization schemes were evaluated. A new method of nasal analysis for the African American woman uses the proportional relationships of the anthropometric measurements. Proportional relationships included a columellar to lobule ratio of 1.5:1, a nasolabial angle of 86 degrees, and an alar width to intercanthal distance ratio of 5:4. The nasal dorsal height classification scheme was the most reliable for subjective analysis. The degree of variability found within this group of young African American women is illustrated by the following indices and their respective ranges: nose width-nose height index mean, 79.7 (range, 57 to 102); nasal tip protrusion-nose height index mean, 33.8 (range, 23 to 46); and nasal tip protrusion-nose width index mean, 42.8 (range, 32 to 61). The guidelines provided are a baseline from which to begin analysis and evaluation.

Rinoplastia do nariz negróide por via intra-oral sem ressecções externas: avaliação da eficácia da técnica

OBJETIVO: Avaliar a eficácia da técnica de redução da largura da base nasal do nariz negróide, modificando a inclinação dos eixos das narinas pela mobilização de tecidos internos, por abordagem intra-oral, evitando cicatrizes externas. MÉTODOS: Foram operadas 11 pacientes adulta do sexo feminino, com idade variando entre 19 a 45 anos, distribuindo-se em 2 da raça caucasóide e 9 da raça negróide, sendo desta 5 de cor parda e 4 de cor negra. O método de fotografia foi padronizado, e as imagens em papel foram digitalizadas. Por meio de software foram mensurados nas fotografias pré-operatórias e com 3 meses após a rinoplastia, 8 índices relativos à base nasal baseados em pontos antropométricos. Os valores obtidos foram submetidos à análise estatística descritiva e inferencial. RESULTADOS: Não houve diferença estatisticamente significante em 7 índices relativos a redução da largura da base nasal e à inclinação dos eixos das narinas. Apenas houve alteração significante no aumento do Ângulo Nasolabial (p=0,001). CONCLUSÃO: A técnica de rinoplastia de nariz negróide por via intra-oral sem ressecções externas, apenas com mobilização dos tecidos internos, não é eficaz para a reduzir a largura da base nasal.

Nasal base reduction: An updated technique

The author's technique for nasal base reduction continues to be mobilization of the nasal base soft tissues and suturing from one ala to the other. However, he has made some modifications. For example, he advises against performing soft tissue resection of the columellar base tissues, via a buccal sulcus or transfixion approach, in conjunction with an open rhinoplasty. Here, he updates his technique. ( Aesthetic Surg J 2002;22:289-291.)

The nasal base in cleft lip rhinoplasty.

The discussion on how to correct the nasal base in cleft lip (CL) rhinoplasty focuses on timing of the surgery, the type of approach, and the technique of repositioning the ala. Little attention is paid to the nasal vestibule. We compared the results of two different techniques. Forty-two patients were operated on via an endonasal approach with total mobilization of the lateral crus and fixation after repositioning. An external approach was used in 12 patients and the lateral crus freed as a medially based chondrocutaneous flap. The defect in the lateral vestibule wall was covered with an ear composite graft. The latter group showed more stable results concerning symmetry and breathing. We conclude that in most cases of unilateral CL noses there is not only a malposition and deformity of soft tissues and skin of the ala, but also a deficiency in the surface of inner lining of the nasal vestibule that needs appropriate repair. In general, the numerous procedures for repair of the nasal base in unilateral CL patients can be attributed to three principles based on different philosophies concerning the underlying pathology.

Lip repair techniques and their influence on the nose.

The cleft nose has long been a problem when closing the lip in a cleft palate patient. More today than in the past, close attention is paid to the outcome of the nasal form, nasal base, and the position of distorted structures like the alar cartilage and the septum. The different techniques of lip closure can be used simultaneously with the nasal correction. But different methods of lip repair without primary nasal correction also influence the nasal form. It seems that the reconstruction of the nasolabial muscles (including the orbicularis muscle) is an important factor to gain a symmetrical nose after the primary operation. Although the results are very promising, it cannot be stated that no further operations will be needed later. But since growth disturbance has not been reported until now, most of the authors dealing with primary nasal correction recommend it simultaneously with the lip repair. Further investigations are needed to define the outcome after the cessation of growth.

Secondary Cleft Lip Rhinoplasty

[]Without any doubt, rhinoplasty in adults or adolescent patients born with clefts of the lip, combined with clefts of alveolus and palate, is most challenging. In unilateral clefts, the asymmetry of the nasal base is the most striking aesthetic feature. The surgeon is confronted with scars, deformed and displaced cartilages, and abnormal soft tissues, which sometimes seem to resist all attempts to move and hold them in the desired position. Residual or recurrent asymmetries are often attributed to this ``memory-effect.'' The technical procedures to overcome this tendency and correct the nasal deformity are numerous and it is difficult to evaluate their effectiveness.

The deviated nose

Steve H. Byrd, MD Peter McKinney, MD Jack P. Gunter, MD Ira D. Papel, MD Dr. Byrd: The first patient is a 28-year-old man who sustained a very typical nasal fracture on the right side at about the junction of the thick and thin portion of the nasal bone while playing basketball (Figure 1). He understands that his nose is deviated to the left, complains of a partially diminished airway on the right, and asks, “While you're at it, could you take that bump off my nose?” Dr. Gunter, how would you approach this patient? Dr. Gunter: It appears that the nasal base is a little wide. The one-sided fracture has deviated the nose to the left with collapse of the right upper lateral cartilage. On the lateral view, the nasal frontal angle is very shallow with a slight amount of increased tip projection and a small dorsal hump. Dr. Byrd: How would you explore this patient's aesthetic goals, and how would you go about achieving them? Dr. Gunter: I have large-scale patient photographs taken in the office over which I tape tracing paper. I draw on the photographs after getting feedback from the patient. I revise the drawing until I achieve what the patient would like. If I think it is reasonable, I explain that this will be the “goal” for the surgery, not exactly what the patient will look like. Although I usually employ an open approach, it really will not be necessary if I plan on doing a very small rasping of the dorsum, leaving the tip projection alone. I would do osteotomies on the right side while the septum remains deviated and see whether that corrects the curvature of the nose or just corrects the problem on the right. If the septum remains deviated, I would …

Alar rim deformities.

Alar disharmony is one of the most common abnormalities observed after a rhinoplasty. This article describes three classes in addition to Gunter's classifications of alar/columella deformities, which include concave ala, convex ala caused by convex lateral crus, and convex ala caused by thick alar tissues. These deformities are best visualized from the basilar view. The different surgical techniques for correction of true alar abnormalities are presented. The alar convexity, when it is the result of a misshapen cartilage, is corrected using a lateral crura spanning suture, posterior transection of the lateral crura, or transdomal suture. A thick ala, resulting in convexity, can be thinned through either a direct incision on the ala or an incision in the alar base. A lateral crura strut, an onlay graft, or a rim graft eliminates the concavity. For a slight retraction, an alar rim cartilage graft is an optimal choice. For significant alar retractions, the author's preferred technique is an internal V-to-Y advancement, which is described in detail. An elliptical excision of the alar lining will effectively correct the hanging ala. These techniques have been used to correct alar disharmonies on 58 patients. One patient from the V-Y advancement group exhibited a small area of alar necrosis, and two early patients demonstrated an overcorrection; all were easily resolved with revision surgery. By carefully identifying nasal base and alar abnormalities, harmony can be established to correct an undesirable appearance.

Dynamic rhinoplasty for the plunging nasal tip: functional unity of the inferior third of the nose.

To achieve permanent results for the correction of a drooping nasal tip, it is important to understand the mechanism responsible for the caudal rotation of the tip when a person speaks or smiles. This mechanism can be considered to depend on a "functional unity" formed by three components: (1) the cartilaginous framework (alar cartilages and accessories acting as a single structure); (2) muscular motors (m. levator labii superioris alaeque nasi and depressor septi nasi); and (3) gliding areas (apertura piriformis, the valvular mechanism between the upper lateral cartilages and alar cartilages, the lax tissue of the nasal dorsum, and the membranous septum). We describe a new anatomical and functional concept responsible for the plunging of the nasal tip. When a person smiles, the functional unit is activated by a combination of two forces acting simultaneously in opposite directions that rotate the tip caudally and elevate the nasal base. The levator moves the alar base upward and the depressor pulls the tip caudally. To correct the drooping tip, the transcartilaginous incision is extended laterally, and the lateral portion of the alar arch is dissected free from the skin and the mucosa, thus exposing the accessory cartilages. The arch is then severed at the level of the accessories to allow the cephalad rotation of the domes. The muscle insertions are dissected free from the accessories and a section of the muscle and, if necessary, the accessory cartilages, is removed. From January of 1991 onward, 312 patients have had this ancillary procedure performed in addition to the basic rhinoplasty technique.

Structure concept in nasal tip surgery

When performing nasal tip surgery, a stable nasal base is critical in providing a good long-term outcome. Weakness in the nasal base can result in postoperative loss of nasal tip projection. Patients with a deficiency in the nasal base include those with inadequate tip projection, acute nasolabial angle, and dependency of the nasal tip. Maneuvers used to stabilize the nasal base include a sutured-in-place columellar strut, caudal extension graft, setting back and fixating the medial crura to an overly long caudal septum, or use of an extended columellar strut fixated to the periosteum about the nasal spine. Once the nasal base is stabilized, the lobule can be modified using domebinding sutures or a sutured-in-place tip graft. Use of these maneuvers can provide maximal tip projection with good tip contour. This article will discuss the principles behind the use of these techniques and discuss the nuances related to execution of the maneuvers.

Laser-assisted columelloplasty

The nasal base is a very complex district because of the dynamic relationships between skin, subcutaneous tissue, underlying muscle, and cartilaginous structures. The nostril in particular is the air gate of the nasal fossa in which small deformities may severely impair the dynamic of nasal air flow. The anatomy, function, morphology of the structures, and the importance of the columella in the reduction of nasal air flow are discussed. A new method for columellar refinement, laser-assisted columelloplasty (LACP) is described. The new laser technique has numerous advantages—it can be performed under local anesthesia, it has high surgical accuracy, there is minimal bleeding with no need for postoperative nasal packing, and the recovery time is quick, all with respect to improving nasal anatomy and physiology. This article emphasizes the value of the surgical nasal sculpturing technique and the achievement of an improved functional as well as aesthetic result.

Management of the Bulbous Nose

"Bulbous nose" is a term patients often use to describe a "ball" on the end of their nose. This ball can be caused by the abnormal anatomy of alar cartilage or by the overlying soft-tissue coverage. The purpose of this article is to analyze the different causes of bulbous noses and their treatment options. An analysis was done based on four decades of experience and long-term follow-up. We included 10 patients for our discussion. The relationship of the tip to the vault must be analyzed, because it can create optical illusions. For instance, a low bridge makes the tip appear larger; therefore, a bulbous nose may be relative. Similarly, excessive narrowing of the nasal base by alar wedges makes the tip appear wider. Intrinsic causes of a bulbous nose include skin, subcutaneous tissue (including the nasal superficial musculoaponeurotic system, ligaments, and fat), and the shape and direction of the individual crus. Nasal skin varies as to volume and ability to contract; therefore, the shape, direction, or divergence of the individual crura cannot undergo unlimited modifications. There are several surgical possibilities for a given problem. Making the diagnosis of the underlying abnormal anatomy is the most important step; then the most appropriate operation can be selected. Struts, sutures, resection, dome division, and/or dorsal augmentation are all viable options for the management of the bulbous nose.

Management of the Bulbous Nose

"Bulbous nose" is a term patients often use to describe a "ball" on the end of their nose. This ball can be caused by the abnormal anatomy of alar cartilage or by the overlying soft-tissue coverage. The purpose of this article is to analyze the different causes of bulbous noses and their treatment options. An analysis was done based on four decades of experience and long-term follow-up. We included 10 patients for our discussion. The relationship of the tip to the vault must be analyzed, because it can create optical illusions. For instance, a low bridge makes the tip appear larger; therefore, a bulbous nose may be relative. Similarly, excessive narrowing of the nasal base by alar wedges makes the tip appear wider. Intrinsic causes of a bulbous nose include skin, subcutaneous tissue (including the nasal superficial musculoaponeurotic system, ligaments, and fat), and the shape and direction of the individual crus. Nasal skin varies as to volume and ability to contract; therefore, the shape, direction, or divergence of the individual crura cannot undergo unlimited modifications. There are several surgical possibilities for a given problem. Making the diagnosis of the underlying abnormal anatomy is the most important step; then the most appropriate operation can be selected. Struts, sutures, resection, dome division, and/or dorsal augmentation are all viable options for the management of the bulbous nose.

Noonan syndrome: a cryptic condition in early gestation.

Noonan syndrome is one of the most common of genetic syndromes and manifests at birth, yet it is usually diagnosed during childhood. Although prenatal diagnosis of Noonan syndrome is usually not possible, in a few cases the ultrasonographic findings suggested the diagnosis in utero. Reported sonographic clues include septated cystic hygroma, hydrothorax, polyhydramnios, and cardiac defects, such as pulmonic stenosis and hypertrophic cardiomyopathy. During a 6-year period, 46,224 live-born infants were delivered at the Chaim Sheba Medical Center. Seven newborn infants and four fetuses were found to have Noonan syndrome. One fetus showed transient nuchal translucency of 4 mm and bilateral neck cysts at the 13th gestational week. Both findings resolved spontaneously by the 18th gestational week, but during the third trimester this fetus developed hydrothorax, skin edema, and polyhydramnios. In the three other fetuses, first- and second-trimester ultrasonographic findings were normal, and the diagnosis of Noonan syndrome was suggested only during the third trimester. All three fetuses had polyhydramnios and skin edema. A cardiac malformation, hydrothorax, and a large head were present in one fetus. Sonographic facial findings were investigated. In all four fetuses posteriorly angulated, apparently low-set ears and depressed nasal bridge were identified. Wide nasal base was seen in two fetuses. In two fetuses, persistent opening of the fetal mouth was interpreted as fetal hypotonia. One fetus developed progressive postnatal hypertrophic cardiomyopathy and in one case, pulmonic stenosis became apparent at age 6 months. This small series suggests that Noonan syndrome has an evolving phenotype during in utero and postnatal life. Amelioration of early nuchal region findings and late onset of the more "typical" ultrasonographic changes may limit early prenatal detectability.

Three dimensional laser scan assessment of the Oriental nose with a new classification of Oriental nasal types

The Oriental nose, which has been broadly classified as mesorrhine, differs in anatomy and morphology from other racial groups. The objective of this study is to carry out anthropometric measurements in the nose region, in order to establish norms for the Oriental nose and also to identify the variations that might occur within this group. Knowledge of the unique shape, anatomy and dimensions of the Oriental nose would be very useful for surgeons undertaking repair and reconstruction of Oriental noses. Ninety, normal Oriental subjects were scanned using a laser surface scanner, and the assessments were then carried out on the laser scan images. The 3-D laser scan images permit adjustment and positioning to achieve the correct standard views for assessment. Subjective assessment of the nose shape, as well as linear and angular measurements were carried out. Depending on the fullness and roundness of the nasal tip and the prominence of the alar lobules on either side, the Oriental nasal base may take on varied shapes and accordingly, three distinct shapes have been identified. They have been classified into types A, B and C where type A has a very prominent alar lobule and a full and rounded nasal tip. In type B, the alar lobule was less prominent and the nasal tip was more defined while in type C the alar lobule was the least prominent resulting in the lateral walls forming a relatively straight slope from the tip to the alar base. The linear and angular measurements for Oriental noses were also obtained and compared to values for other racial groups. The proportion indices for the Oriental nose showed that it was broader in relation to the nose height, and had less tip protrusion in relation to both the height and width of the nose. The data collected from this study can be used as norms for Oriental cases and the simple classification of the nose shape will serve as a guide for quick reference, when planning aesthetic or reconstructive rhinoplasties for the Oriental patient.

Long Term Effects of the Latham Presurgical Maxillary Orthopedic Appliance, Including Effects on Tooth Growth

Reported beneficial effects of presurgical maxillary orthopedics in cleft lip include reduction of the cleft width, alignment of the maxillary segments, elevation of the alar base on the cleft side, diminished need for alveolar bone grafting and lip closure without tension. Possible adverse effects of presurgical maxillary orthopedics include tooth root damage and inability of periosteoplasty to make bone over the cleft. A series of wide cleft lip patients (n=15) treated with the Latham appliance at the time of lip closure were retrospectively compared with a similar group treated without the Latham appliance. The Latham appliance group (seven unilateral clefts, eight bilateral clefts; mean follow-up 9.5 years; range four to 18 years) was treated between the years 1980 and 1994. None of the 15 patients treated with the appliance had any tooth loss or damage attributable to the pins, and bone formation in the alveolar cleft was observed radiographically in all 13 of the patients who had a periosteoplasty at the time of lip repair, possibly obviating the need for secondary bone grafting. Five of these Latham group patients demonstrated clinical and radiographic evidence of tooth eruption into the periosteoplasty-formed bone. There was no consistent difference in the level of nasal alar base elevation in the two groups.

NASAL BASE SURGERY

Nasal base surgery is a challenging and yet rewarding part of rhinoplasty. The nasal base, the most frequently ignored view of the nose, provides important information with regards to projection, lobular anatomy, nostril size, and overall aesthetics of the nose. This article reviews the anatomy of the nasal base and its surrounding structures, as well as aesthetically pleasing proportions of the nasal base in context of facial analysis. Specific criteria for evaluating discrepancies of the alar-columellar relationship also are described, as well as aesthetic rhinoplastic techniques to correct them.