Nasal Lengthening Research Articles

The Caudal Septum Pivot Technique for Short Nose Correction.

The short nose represents one of the greatest challenges in rhinoplasty. It is characterized by a reduced distance from the nasal radix to the tip-defining points, often associated with inadequate tip projection. Several techniques have been described for correction of short nose with the common objective of replacing and rebuilding the osteocartilaginous framework. One of the most effective method to correct the short nose is the septal extension graft. The authors describe the caudal septum pivot (CSP) technique, a simple method to elongate short noses by using a graft inserted in the dorsal septum after its division using as pivot the caudal portion, without detaching it from its natural anchorage to the anterior nasal spine. A retrospective analysis was performed reviewing the clinical charts and the operative records of 315 patients who underwent revision rhinoplasty from January 2015 to June 2019; among this group, 34 were considered eligible for the study. The patients (8 men, 26 women; mean age: 25.4 years; age range: 22-53 years) were divided into two groups: in 12 patients (Group 1) the CSP technique was performed, while Group 2 was composed of 22 patients who received a more classic treatment with a septal extension graft. To evaluate the outcomes, nasal length, tip projection, and tip rotation were measured pre- and 1 year postoperatively on digital photographs of each patient. Nasal anthropometric measurements revealed, at 12-month visit follow-up, an improvement in nasal length, tip projection, and nasolabial angle was achieved in all the patients. The comparison of the pre- and postoperative values showed a statistically significant reduction in the nasolabial angle (p < 0.05) and an increase in the tip projection (p < 0.05) and in the nasal lengthening (p < 0.05) in both groups. In authors' experience, the CSP technique could be considered a safe, reliable, and effective alternative technique in selected patients.

A Comparative Study Between Classic Derotation Graft and Novel Double V Cutting Folded Derotation Graft

To introduce an innovative refinement, the "double V cutting folded derotation graft" (DVCFD graft), which is a method for nasal tip lengthening in aesthetic rhinoplasty with strong holding force and efficient cartilage use. A retrospective study was conducted from January 2018 to July 2019 with 101 patients, including 11 males and 90 females with an average age of 36.87 ± 10.12 years, at Chang Gung Memorial Hospital; the patients received classic derotation grafts (n = 49, 17 of them were one layer and 32 of them were two layers) and DVCFD grafts (n = 52) for cosmetic tip plasty. The tip projection, columella labial angle and nasolabial angle were measured through clinical photography at three different times (T0: pre-operation, T1: two weeks post-operation and T2: five months post-operation). The differences between the original derotation graft and the DVCFD graft were identified using paired-t and independent-t tests. The final relapse ratios of the classic derotation graft and DVCFD graft were 36.78% versus 36.92% for tip projection, 40.65% versus 38.58% for columella labial angle and 45.00% versus 47.76% for nasal labial angle, respectively. The P values of the independent-t tests were 0.991, 0.564 and 0.439, respectively. Both the classic derotation graft and DVCFD graft possess similar stability in tip plasty. The novel modification of the DVCFD graft has more efficient cartilage usage and is a feasible and safe surgical option for patients with limited harvestable cartilage for tip lengthening. 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 .

Correction of secondary unilateral cleft lip nasal deformity in adults using lower lateral cartilage repositioning, columellar strut, and onlay cartilage graft on the nasal tip with open rhinoplasty combined with reverse-U incision

A rhinoplasty technique involving lower lateral cartilage (LLC) repositioning and grafting of ear cartilage allows for nasal lengthening and nasal tip mobility. For better esthetic outcomes in patients with cleft lip nasal deformity (CLND), we combined cosmetic nasal tip plasty with standard techniques. We performed open rhinoplasty combined with reverse-U incision and V-Y plasty in 62 patients with secondary unilateral CLND from October 2013 to June 2018. Both LLCs were isolated, repositioned, approximated medially, and advanced with a Medpor strut, followed by tip suture technique. To further project and enhance the nasal tip and columella, application of ear cartilage onlay graft was used. As adjunctive procedures, septoplasty or osteotomy was carried out for correction of septal or nasal bone deviations, respectively. Photogrammetric evaluations of patients and statistical analyses were performed. Average age at operation was 23.5 years (range: 18-42 years). Of the 62 patients, 15 underwent dorsal augmentation with silicone implant. Two-layer conchal cartilage onlay grafting was performed to manage tip height. Outcomes in 34 patients were analyzed with pre- and postoperative photography. Nasal tip projection increased, alar base width index decreased, and alar and columellar symmetry significantly improved. No Medpor implant exposure or other adverse outcomes occurred. The proposed technique is effective for correcting secondary unilateral CLND and achieving a satisfying nasal appearance in adults.

Role of New Intercartilaginous Suturing Technique in Maintaining Nasal Tip Support Mechanism Following Rhinoplasty

Background: Nasal tip support mechanism plays an importantrole in maintaining tip in its position and preventingdrooping of nasal tip and nasal lengthening. In rhinoplastysurgery, this mechanism can be excised or detached duringdifferent steps of rhinoplasty, in our practice we detach threeattachments which play an important role in tip support;attachment in-between the caudal septum and foot plates ofmedial crura which can be replaced by medial crural septalsuture, interdomal attachment also can be replaced by interdomalsuturing, while the attachment in-between upper andlower lateral cartilages, which is usually detached duringcephalic trimming of the lower lateral cartilage, is not replacedby any type of suturing technique. In this study, we describeda new intercartilaginous suturing technique to reattach thisattachment with the remaining part of lower lateral cartilage.We aimed to analyze the log-term effect of re-attachment ofthe ligament between upper and lower lateral cartilages ontip support, projection and rotation.Material and Methods: Twenty four patients were includedin this study; group I included 12 patients had underwentaesthetic rhinoplasty surgery without applying intercartilaginoussuture, while in group II, the new suture wasapplied in 12 patients during rhinoplasty. In both groups,nasolabial angle and projection/ nasal length ratio in theprofile view of patients' photographs were measured at 1.5,3 and 6 months post-operatively as well as, patient's satisfactionregarding aesthetic outcome was subjectively evaluated by aquestionnaire at 6 months post-operatively.Results: The study revealed that nasal tip position wasmaintained in group II more than group I in a period of 6months following rhinoplasty surgery with more patientsatisfaction score in group II of patients as well.Key Words: Primary rhinoplasty – Open rhinoplasty

EVALUATION OF SEPTAL EXTENSION GRAFT IN RHINOPLASTY

Septal extension graft is a unique technique for controlling nasal lengthening and tip projection, rotation, and shape by which a graft is fixed to the septum, leading to a strong and stable supporting structure. Nasal tip three-dimensional positioning is a vital and difficult component in the overall appearance of the tip. A total of 12 Middle Eastern patients with thick nasal envelope skin were subjected to rhinoplasty using the septal extension graft (SEG) method. Eleven out of the 12 patients, had pleasing results after primary rhinoplasty with SEG, while only one patient had SEG as a secondary procedure. In conclusion, septal extension graft in rhinoplasty is an effective technique for achieving a strong supporting force of the nasal tip for adequate projection. Keywords: Nasal tip, surgery, septal extension, graft, rhinoplasty

Anatomical repair of a bilateral Tessier No. 3 cleft by midfacial advancement

BackgroundBilateral Tessier number 3 clefts are extremely rare, and their surgical treatments have not been well established.Case presentationThe authors describe the case of a patient with a right Tessier number 3, 11 facial cleft with microphthalmia, a left Tessier number 3 facial cleft with anophthalmia, and cleft palate. We repaired simultaneously the bilateral soft tissue clefts by premaxillary repositioning, cleft lip repair, facial cleft repair by nasal lengthening, midfacial advancement, and an upper eyelid transposition flap with repositioning both the medial canthi. Postoperatively, the patient showed an esthetically acceptable face without unnatural scars.ConclusionsWe achieved good results functionally and esthetically by midfacial advancement with facial muscle reposition instead of traditional interdigitating Z-plasties. The surgical modality of our anatomical repair and 3 months follow-up results are presented.

Application of perpendicular plate of ethmoid bone in short nose plasty in Chinese with insufficient septal cartilage

Objective To evaluate the applied value of septal cartilage combined with perpendicular plate of ethmoid bone graft in short nose plasty in Chinese people with insufficient septal cartilage. Methods From February 2015 to March 2017, thirty-five women with short noses underwent septal extension grafting in our institute. We used perpendicular plate of ethmoid bone to enhance the L-strut structure. An L-strut, comprising 0.6 cm segments of the caudal and dorsal cartilaginous septum, was left altered to harvest more cartilages for septal extension. The harvested septal cartilage was grafted on one side of the caudal septum. Then the alar cartilage was fixed at the end of the septal cartilage graft. Nasal lengths and nasolabial angles were measured pre- and postoperatively. Results The average nasal lengthening was (3.37±1.87) mm (P<0.001). There was no infection, cerebral spinal fluid leakage, hemorrhage and other complications postoperatively. The average follow-up was 10 months (6 months to 2 years). After operation, 33 patients were satisfied with the nasal contour, 1 patient complained of high tip projection whereas one patient complained of low tip projection, and the dissatisfactions were corrected by revision surgeries. Conclusions Combining the septal cartilage with perpendicular plate of ethmoid bone graft presents an adequate nose lengthening and a decreased nostril show, even in patients with very little septal cartilage. With minimum complications, this novel technique provides promising clinical outcomes and high patient satisfaction. Key words: Short nose; Perpendicular plate of ethmoid bone; Septal reinforced implant; Rhinoplasty

Application of a Porous Polyethylene Spreader Graft for Nasal Lengthening in Asian Patients.

Rhinoplasty maneuvers to lengthen the nose include placing an alloplastic implant, caudally rotating the lower lateral cartilage (LLC), and stretching the soft tissue skin envelope (STSE) downward. Tissue tension associated with these procedures can result in implant extrusion or tip retraction. The authors performed rhinoplasty with implantation of porous polyethylene (Medpor). The Medpor device enabled transfer of tension from the LLC and STSE to the juncture of the septal cartilage and upper lateral cartilage (ULC), thereby stabilizing the nasal structures. Twenty-six patients who underwent rhinoplasty with nasal augmentation and lengthening were evaluated in a prospective study. Two pieces of Medpor were placed as a spreader graft, and a third piece was inserted as a columellar strut. The released LLC was rotated caudally, and the domal segments were wrapped over the caudally projected tip of the implant. Surgical outcomes were assessed with a patient satisfaction questionnaire and by photogrammetry. Patients were monitored for an average of 9.6 months. The patients' mean nasolabial angle (NLA) was 106.2° ± 4.7° preoperatively and 94.3° ± 3.7° postoperatively (t < 0.0001). Most patients were fairly or completely satisfied with the operative outcome. One patient had impending implant extrusion and underwent explanation. Medpor material is easy to shape and is sufficiently strong to function as a spreader graft and withstand the tension associated with repositioning of the LLC and STSE.

Commentary on: Application of a Porous Polyethylene Spreader Graft for Nasal Lengthening in Asian Patients.

Commentary on: Application of a Porous Polyethylene Spreader Graft for Nasal Lengthening in Asian Patients.

Nasal tip surgery: nasal lengthening and augmentation in Asian rhinoplasty

Nasal tip surgery: nasal lengthening and augmentation in Asian rhinoplasty

Septal Cartilage/Ethmoid Bone Composite Graft: A New and Improved Method for the Correction Underdeveloped Nasal Septum in Patients with Short Noses.

Septal extension grafts are an effective means of extending nasal length in patients with a short nose. However, such grafts can be challenging in patients who only have small quantities of weak septal cartilage, such as some East Asian patients. We developed a rhinoplasty technique using ethmoid bone to create a cartilage-bone complex to overcome this issue, allowing adequate nasal lengthening. Sixty-four women with short noses and inadequate septal cartilage determined by preoperative computed tomography underwent septal extension grafting with a cartilage-bone complex between January 2009 and December 2014. Septal cartilage and ethmoid bone were harvested during open rhinoplasty and secured to the septal cartilage. Most patients were in their twenties or thirties. All patients underwent septal extension grafting using a cartilage-bone complex and dorsal augmentation with silicone implants. Short nasal length, decreased nasolabial angle and increased nostril show, were rectified. There was no recurrence during a mean follow-up period of 12.3months, although one patient (1.5%) requested revision surgery. Septal extension grafting with a cartilage-bone complex can be used to correct a short nose, especially in Asians who have relatively small amounts of septal cartilage. The ethmoid bone augments the inadequate septum and provides structural support. 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 .

An Economical Approach to Ethnic Asian Rhinoplasty

Septal cartilage is deficient in Asians seeking augmentation rhinoplasty. Economized utilization of resources is necessary for durable tip enhancement that complements a dorsal implant. We introduce a modified tongue-in-groove method designed to transmit forces across the dorsum, eliminating the need for robust caudal support and prioritizing nasal lengthening and tip projection. We aim to promote the roundness index parameter and demonstrate the feasibility of a novel method in the context of Asian rhinoplasty. Between 2012 and 2014, a total of 104 Taiwanese patients underwent rhinoplasty with dorsal augmentation and lengthening with a modified tongue-in-groove technique. The concept borrows from methods established by Byrd, Guyuron, and Toriumi but distinguished by exaggerated forward positioning of a septal extension graft. Paired extended spreader grafts obviate the need for a columellar strut. Soft-tissue changes were analyzed with photogrammetry. A new parameter, the roundness index, was measured. Tip projection, dorsal length, nasal height, alar and columellar length increased significantly after 5.5 months of follow-up. Nasal tip angle, roundness, columella-labial angle, and nostril axis inclination decreased. There were no statistically significant differences in the magnitude of change in patients followed for less than and greater than 6 months. The most common complication was new or persistent tip deviation in five cases (5%). This technique was designed for a nasal anatomy typified by deficient septal cartilage. Significant photogrammetric changes were maintained after 6 months. Economized tissue allocation, dorsal septal load sharing, and relative independence from caudal support are key features of this feasible method.

Correction of severe columella and tip retraction in silicone implanted Asian short noses.

BackgroundSilicone Implants and other alloplastic materials are frequently used in rhinoplasty to augment Asian short noses. However, nasal deformities as a result of implant-related infections are increasing in incidence. The resulting tissue scarrings hinder the application of traditional techniques of lengthening short noses. The following paper presents a technique to correct severe postoperative retractions of the tip and columella caused by silicone implants.MethodsWe present a retrospective case study of two Asian patients with recurrent acute infections, secondary to silicone dorsum implants, leading to chronic inflammation of the tip and columella. The treatment consisted of implant removal and the immediate nasal reconstruction by combining uni- or bilateral gingivobuccal flaps along with L-shaped costal cartilage grafting.To evaluate the surgical results, various anthropometric measurements, particularly the nasal length (NL) and nasal tip projection (NTP) of pre- and postoperative profile photographs, were analyzed.ResultsSuccessful nasal lengthening and correction of columellar retraction were achieved. In case I, postoperative NTP and NL increased by 34.7 % and 21.1 %, respectively. In case II, NL and NTP increased by 23.8 % and 10.6 %, respectively. However, case II presented necrosis of the distal extremity of one gingivobuccal flap without rib graft resorption, which later healed by secondary intention.ConclusionPronounced columellar retraction in severe short noses can be successfully managed with a combination of gingivobuccal flaps along with L-shaped costal cartilage grafting. The use of autologous materials decreases the risk of long-term extrusion through the tip. The gingivobuccal flap provides vascularity to the exposed rib cartilage on the columella and prevents its resorption.

An Introduction to the Septal Extension Graft

The septal extension graft is a very useful method of controlling nasal lengthening and tip projection, rotation, and shape by fixing a graft to the septum, which leads to a strong supporting structure. Enhancing graft stability is important for better long-term outcomes and minimizing complications or relapse, and even more efficient application of these methods is needed for East Asians who lack enough cartilage to be harvested in addition to possessing a weak cartilage framework. In this paper, the methods for overcoming the drawbacks of the septal extension graft, such as instability, a fixed tip, and insufficiency of cartilage, are presented, and the applications of each method for greater satisfaction with surgical outcomes are also discussed.

Lengthening the Short Nose in Asians

Using objective anthropometric measurement, this study reports the outcome of surgical correction of short-nose deformities in Asian patients. To present our experience in lengthening the short nose in Asians and report the surgical results. In this retrospective review, we study the cases of 36 patients who underwent surgical correction of short-nose deformity. The effect of nasal lengthening was analyzed using anthropometric measurement, including nasion to tip-defining point (N-TDP), nasal tip projection (NTP), nasofrontal angle (NFA), and columellar-facial angle (CFA). Surgical correction of short-nose deformity. The preoperative and postoperative N-TDP, NTP, NFA, and CFA and patient satisfaction. The mean postoperative follow-up duration was 29.8 months. The cause of the short nose was congenital in 18 cases and secondary to previous rhinoplasty in 18 cases. Septal tissue, conchal cartilage, costal cartilage, and conchal composite tissue were used as graft materials. The key procedures for lengthening included septal extension graft reinforced with extended spreader, dorsal onlay, and tip grafts. The N-TDP increased by 11.2%, and CFA decreased from 122.6° to 111.1°. The NFA changed from 148.9° to 148.5°. The NTP ratio, measured using the Goode method, decreased from 0.53 to 0.50. The increase of N-TDP was greater in patients undergoing the costal cartilage grafting procedure than in those who received septal or conchal cartilage. All patients were satisfied with the aesthetic results, and there were no serious complications. In Asians, the key maneuvers for lengthening were septal extension graft reinforced with extended spreader and dorsal onlay graft. Rib cartilage provided superior lengthening effect compared with other cartilage. 4.

Correction of asian short nose with lower lateral cartilage repositioning and ear cartilage grafting.

Asians with short nose lack the cartilage needed to extend the length of the nose. A rhinoplasty technique using lower lateral cartilage (LLC) repositioning and ear cartilage grafting allows for sufficient nasal lengthening and nasal tip mobility in the correction of short nose in Asians. Short nose was classified into 3 subtypes: type I, II, or III. During LLC repositioning, the LLC was separated from surrounding retaining structures, except at the footplate. The LLC was approximated medially and advanced with a Medpor strut. A silicone dorsal implant was inserted to suit the newly projected nasal tip. An ear cartilage onlay graft or ear cartilage extension graft was applied to further project and enhance the nasal tip and columella. Of the 854 primary rhinoplasty procedures performed on Asian patients between January 2008 and December 2011, 295 were performed on patients with short nose. LLC repositioning and ear cartilage onlay grafting were performed on 228 patients. LLC repositioning and ear cartilage extension grafting with or without ear cartilage onlay grafting were performed on 67 patients. Short nasal tip, alar retraction, and columellar retraction were corrected. Wound dehiscence with marginal necrosis occurred in 7 patients. One patient developed nasal infection. LLC repositioning and ear cartilage grafting aid in the correction of short nose in Asians. With LLC repositioning and ear cartilage grafting, the nasal tip can be positioned in accordance with the patient's anatomic limits. The entire nasal tip and columella can be lengthened, while the tip maintains its mobility.

Effect of the Depressor Septi Nasi Muscle on Nasal Lengthening Over Time

Effect of the Depressor Septi Nasi Muscle on Nasal Lengthening Over Time

Effect of Depressor Septi Nasi Muscle Activity on Nasal Lengthening With Time

The depressor septi nasi (DSN) muscle is an important muscle in nose dynamics. Its hyperactivity causes smile deformity including nasal tip depression. The nasal tip of individuals with a hyperactive DSN muscle depresses repeatedly while they are speaking and smiling. This may result in nasal lengthening as they age. Pairs of cases consisting of a child and one of his or her parents were studied in two groups: case group (with DSN muscle hyperactivity) and the control group (with DSN muscle inactivity in both child and parent). Nasal length from nasion to tip and facial length from nasion to menton were measured during repose and during smiling. This study investigated 80 pairs of children and parents. In both groups, a significant linear correlation between the nasal length of the parent and the child was found. In both groups (case and control), the nasal length of the child differed significantly from that of the parent. The increase in the nasal length of the parents compared with the children was greater in the control group. This study demonstrated that nasal length increases with age and that DSN muscle hyperactivity is not an effective factor in this increase. This unpredictable result may affect the presumption that patients with DSN muscle hyperactivity will have longer noses in the future. Long-term prospective studies investigating cohort groups are required to clarify the variables affecting nasal lengthening with aging, and interventional studies are needed to examine the effects of DSN muscle resection on this phenomenon.

Correction of Difficult Short Nose by Modified Caudal Septal Advancement in Asian Patients

Correction of a short nose, defined by a reduced distance from the nasal radix to the tip, has been regarded as one of the most challenging procedures in rhinoplasty. Some short nose cases are too difficult to treat with conventional grafts because of their scanty, flimsy, pliable, or deviated septum or depleted donor supply of septal or conchal cartilage. Although costal cartilage graft may be an option, patients may be reluctant to undergo this invasive surgery. The author presents his two-year aesthetic results from the treatment of difficult short noses with the modified caudal septal advancement method. From November 2006 to August 2008, 41 patients (ages 23-59 years) with a short nose were treated with modified caudal septal advancement, with or without extracorporeal septoplasty. Among the 36 patients who remained for six months to two years of follow-up, 20 patients achieved "excellent" results and 12 patients showed "good" results, both based on nasal lengthening measurements taken by the author. Four patients had only "fair" results. Patients in this last group, including three with overlengthening and one with inadequate elongation, required revision surgery. In the Asian population, when short-nosed patients present with weak or deviated caudal septums or a limited supply of donor conchal or septal cartilage, the modified caudal septal advancement method can more predictably and efficiently provide a stable nasal base support than the conventional extension grafts, spreader grafts, or extended spreader grafts. The author believes that this technique is a safe, effective, and reliable alternative to costal cartilage grafts in dealing with difficult short noses.

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.