Nasal Lobule Research Articles

Three-dimensional analysis of autologous costal cartilage in Asian secondary unilateral cleft rhinoplasty

This study describes a surgical technique for secondary unilateral cleft rhinoplasty using autologous costal cartilage grafts. The grafts were designed preoperatively and analysed three-dimensionally in 15 Asian patients using a photogrammetric camera. Detailed measurements of the nasal anatomy were taken both preoperatively and postoperatively; the same measurements were also taken from the pre-planned images of the anticipated result. When compared to the preoperative measurements, the postoperative three-dimensional outcome analysis revealed several statistically significant improvements in the nasal appearance: nasal dorsal length (P < 0.001), nasal column height (P = 0.001), nasal column width (P = 0.002), nasal lobule height (P = 0.008), cleft side nostril height (P < 0.001) and width (P < 0.001), columella–labial angle (P = 0.001), and nasal tip projection to nasal dorsum length ratio (NTP/NDL) (P = 0.001). Conversely, the comparison of the postoperative and preoperative design measurements showed mostly no statistically significant differences. Thus, utilizing autologous costal cartilage is a reliable approach with predictable and consistent results in secondary cleft rhinoplasty.

Aesthetic Nasal Lobule Correction Using a Three-Dimensional Printed Polycaprolactone Implant.

Nasal tip plasty is a surgery that determines important rhinoplasty outcomes. A variety of autologous and alloplastic implants are utilized in this procedure, including 1 synthetic material known as polycaprolactone (PCL). This study provides background on the ready-made three-dimensional printed PCL implant for nasal lobule correction, before discussing the usefulness and effectiveness of the implant. A total of 23 patients who visited our hospital between January 2018 and January 2020 were evaluated in this study. We used 3 types of PCL implant to get an ideal shape for the nasal tip: tipball (globular shape), droneball (rugby ball shape), and dumbbell (dumbbell shape). The authors compared nasolabial angle and tip projection at the preoperative and postoperative period via photographic anthropometric analysis. In 4 patients, we also examined the dead space between the implant and soft tissue via ultrasonography. The follow-up period averaged 9.5 months and no serious complications were found after surgery. The nasolabial angle and tip projection had an average postoperative increase of 6.4° and 0.044, respectively. Ultrasonography revealed the attachment of the implant at the insertion site and no dead space was found. This is the first attempt to apply a ready-made three-dimensional printed PCL implant to a nasal lobule correction procedure. As the implant was easy to use and showed good results, it may be useful for aesthetic purposes in future nasal tip plasty procedures.

A Global Surgical Journal

A Global Surgical Journal

Preventing Tip Modifications and Alar Retractions: The “Joy-Ride” Stitch

Sir: We congratulate Gruber et al. on their article1 that describes a new technique for correcting tip bulbosity without resecting the cephalic component of the lateral crus. In that technique, the cephalic part of the lateral crus is used as a lateral crural strut and effectively avoids alar retractions. Tip stabilization is an open issue in rhinoplasty, and several techniques have been described over time. At present, the most popular options are medial crural-septal sutures, interdomal-septal sutures, and columellar struts. These techniques are widely used to stabilize the medial crura and to contour tip projection. In primary or secondary rhinoplasty, columellar struts are also evaluated when the nasal tip is underprojected and/or the nasal tip skin is thick. Nevertheless, strut malposition, problems with graft visibility, and unnatural appearance have been described.2 Moreover, tip instability and retraction could occur, especially in tension noses or where the nasal lobule is subject to strain forces, both absolute (where strain forces are applied on the lobule by other nasal structures) and relative (produced by the interface of tip components with different rheologic properties). In fact, the excessive length of triangular cartilages could stress the cranial portion of lateral crura while the overburden size of septal cartilage acts on medial crura. These forces could be magnified by the excessive function of the depressor septi nasi. Tip stabilization and projection have been addressed by several authors who reported different solutions with graft struts, such as the columellar strut-tip graft3 and the dorsal columellar strut.4 Classically, tip stabilization and contouring are performed with a columella-septal suture that affects both tip projection and rotation. This suture could correct an existing hanging columella and provide a small amount of tip projection, whereas greater corrections require columellar struts5 with interdomal-septum or crural-septum sutures. Nevertheless, these sutures could alter the shape of the previously modeled nasal tip, especially where the columella is weak. We propose a different technique for fixing columellar struts to achieve durable tip projection and stabilization without interfering with tip contour. A pocket is dissected between the alar cartilages and the strut graft is placed anterior to the caudal septum (Fig. 1). The strut is sandwiched between the alar cartilages and fixed with a 5-0 Prolene suture. At this point, the graft is secured to the caudal septum with a so-called joy-ride stitch. The joy-ride stitch consists of a simple stitch performed between the columellar strut and the caudal septum (Fig. 2). Strut, alar cartilages, and septum are then fixed together without interdomal-septum or crural-septum sutures, which could alter tip contour in tightening the knot. The placement of the strut is symmetric and precise.Fig. 1.: The columellar strut graft is placed anterior to the septum, thus avoiding alterations in tip symmetry and profile.Fig. 2.: The joy-ride stitch secures the strut graft directly to the septum. The stitch is performed with 5-0 Prolene suture between the lateral edge of the columellar strut and the caudal septum. The placement of the strut is then symmetric and precise, avoiding interdomal-septum or crural-septum sutures that could alter tip contour.In fact, use of the joy-ride stitch, which fixes the strut to the caudal septum, avoids unintended further distortions and gives the surgeon greater control in securing columellar strut grafts. The surgeon is free to model the tip after having placed the strut graft, thus giving predictable, stable, and durable results. DISCLOSURE The authors have no financial interest to declare. Luciano Ariel Lanfranchi, M.D. Riccardo Gazzola, M.D. Franz Wilhelm Baruffaldi Preis, M.D. Unit of Plastic and Reconstructive Surgery IRCCS San Raffaele Hospital, and Unit of Plastic and Reconstructive Surgery IRCCS Istituto Ortopedico Galeazzi Milano, Italy

Rekonstruktive Nasenchirurgie – das Problem der Innenauskleidung

Careful internal defect coverage is important for a well vascularised internal base for the transplant in reconstructive nasal surgery. Secondary healing of intranasal wounds often results in nostril contracture and scar stenosis. The choice of methods for surgical coverage depends on the location of the defect and the condition of surrounding elements. For example, the double-stemmed "pot handle" flap is suitable for small defects of the internal lining of the nasal lobule. The septal mucosa flap can be used for larger and more complex defects of the internal nasal lining. Using composite skin and cartilage grafts from the ear, three-layered nasal defects can be treated in a variety of ways. The turn-in flap is a tilt flap and is very versatile for the treatment of inner defects of the lower nasal half.

New Anatomic Considerations on the Levator Labii Superioris Related With the Nasal Ala

The levator labii superioris (LLS) muscle is well known as one of the upper-lip elevators; however, there have been few reports about the anatomic description of the LLS. Especially, the shape of the LLS and its relationship with the nasal ala were not clearly shown in the literature. The aim of this study was to clarify and describe the morphology and topography of the LLS and the anatomic variations to understand the function of the LLS related with the nasal ala. The LLS was examined in 102 specimens of embalmed Korean and French adult cadavers. The LLS was classified into 3 categories according to its shape and attachment: rectangular (83%), fan (10%), or trapezoid (7%) type. The medial fibers of the LLS were attached to the deep surface of the alar facial crease and were mainly intermingled with the alar part of the nasalis. Some of the deeper muscle fibers of the LLS extended to the vestibular skin of the nasal lobule. These new anatomic findings in the current study could be useful information for understanding the function of the LLS and the various surgical procedures of the perinasal region.

Perspectives on the Evolution of Rhinoplasty

Perspectives on the Evolution of Rhinoplasty

Facial Anthropometric Analysis of the Javanese Female

Facial Anthropometric Analysis of the Javanese Female

Graduated Approach to Refinement of the Nasal Lobule

To present a graduated approach to refining the nasal lobule (a frequent complaint during consultations for rhinoplasty) based on anatomic features and to discuss the casuistics of this procedure since we began performing it. A retrospective evaluation of the medical charts of 1152 patients who underwent rhinoplasty from 2003 to 2006; 641 patients fulfilled the criteria for our study (55.6%). Outcomes were assessed by comparing preoperative and last follow-up photographs and considering the width, symmetry, and contour of the nasal lobule. Cases were allocated into 7 groups: (1) no surgery on nasal tip; (2) interdomal breakup; (3) cephalic trim; (4) domal suture; (5) shield-shaped graft; (6) vertical dome division; and (7) replacement of lower lateral cartilages. Of the 641 patients enrolled in the study, 435 were women and 206 were men. Mean follow-up period was 1.5 years. An asymmetric tip was present in 28 patients (4.4%), and a persistent width of interdomal space in 34 (5.3%). None presented overnarrowing of interdomal space. Surgical revision rate to enhance refinement of the lobule was 5.6%. Our graduated approach has shown excellent outcomes, a high rate of patient satisfaction, and a low rate of revision.

Graduated Approach to Refinement of the Nasal Lobule

Graduated Approach to Refinement of the Nasal Lobule

Nasal Reconstruction After Severe Facial Burns Using a Local Turndown Flap

Reconstruction of the nose after severe burn injury is a challenging problem. There are usually associated facial burns, which limits the availability of local flaps. Reconstruction with unburned distant tissue is often not appropriate because of the resulting mismatch in color and texture. Successful nasal reconstruction can be accomplished in this group of challenging patients using a simple, inferiorly based flap from the nasal dorsum with subsequent skin grafting to the resulting defect. We have used an inferiorly based nasal turndown flap to reconstruct severe nasal deformities after burn injury in 28 patients. The flap tissue consists of the dorsal surface of the nose, which is usually made up of skin graft and scar. The flap base is the scar transition zone between the dorsum of the nose and the lining mucosa. This is turned over to provide nasal length, projection, and to stimulate alar lobules. The resulting defect on the dorsum of the nose is then skin grafted. If further length or refinement is required, the procedure may be repeated. The records of all patients who underwent this procedure were reviewed for demographics, age at burn, percentage of total body surface area burned (%TBSA), availability of the forehead, number of procedures, and complications. Twenty-eight patients underwent nasal reconstruction in our series using this local turndown flap. Most of these patients had severe burns, with an average %TBSA of 46%. The procedure was initially applied to patients with devastating injuries and %TBSA of 80%-95%, with extremely limited donor sites. As the success of the procedure was established, less severely burned patients were included in the series, thereby lowering the mean %TBSA. All patients had partial or complete destruction of their forehead donor site. All patients presented for multiple hospitalizations, with an average of 17 hospital admissions. Using this local turndown flap, adequate nasal length and projection could be achieved. There were few complications. All of the flaps survived, although there were 2 cases of necrosis of the distal edge of the flaps (0.7%). This resulted in decreased length and projection but this problem was successfully addressed with additional staged procedures. Contraction of local scar tissue created bulk and support, eliminating the need for distant tissue transfer or cartilage grafting. Twelve of the 28 patients required repeat turndown flaps to achieve sufficient nasal length and projection. These results were durable over a follow-up period of up to several decades. A simple, multistaged dorsal nasal flap can be used to reconstruct severe nasal deformities after facial burn injury. This can obviate the need for distant tissue transfer. Even in patients with subtotal nasal amputation and complete absence of cartilaginous support, the opportunistic use of scar tissue can restore nasal tip projection and alar lobule architecture without cartilage grafting. The resulting nasal reconstruction blends well into the surrounding facial appearance. This simple technique has been remarkably successful in this selected group of patients with challenging nasal deformities.

A Simplified Use of Septal Extension Graft to Control Nasal Tip Location

For defining the shape and projection of the nasal tip, the bilateral and symmetric batten-type septal extension grafts proposed by Byrd and colleagues have drawbacks. The main problems are stiffness of the nasal tip and thickening of the septum in the nasal valve area. Since 1998, unilateral single-batten grafts, and more frequently, bilateral asymmetric batten grafts as compared with Byrd's bilateral symmetric application, have been used for 72 patients in our facility. At the 6-month postoperative follow-up assessment, tip projection was found to be satisfactory in 61 patients. Less than desired projection occurred in three cases and overprojection in two cases. Nasal lobule deviation was evident in one patient. The loss of the columellar break point was evident in five cases. Unilateral or asymmetric bilateral batten grafts facilitate adjustment of the nasal tip intraoperatively. This technique results in a more pliable nasal tip in the horizontal plane. Construction of a three-layered cartilage in the nasal valve area is not needed, and the nasal airway is preserved. With this modification, a reliable and predictable nasal tip location is obtained with a minimum of graft usage.

Simultaneous reconstruction of upper and lower lip beside chin and nasal lobule: In a case of facial chemical burn

Hypertrophic scarring and contractures that distort the position of facial features and actual loss of facial parts due to burn present a unique reconstructive problem because of the wide variation of skin color and texture present [1–3]. Early reconstruction is indicated in cases with severe disfigurement of face or functional impairment. Small to medium facial skin defects can be reconstructed with local or regional flaps taken above the clavicle [2,4,5]. Large surface defects, however, often require skin grafts, distant flaps, or free flap reconstruction [6–9]. A wide variety of distant flaps now exist for facial reconstruction, although not all provide an adequate tissue match with respect to texture, color, thickness, and pliability [6–8]. Although there are various local and regional flap choices advocated in the literature for reconstruction of nasal defects [3,10–12] but usually the burn is extensive and eliminates most of potential donor sites. A very specific reconstructive problem is the facial hair-bearing skin in the male patients [13–15]. In this situation skin graft and flaps without hair bearing capacity are not suitable. Because of these subtle complexities, careful thought must be given to the selection and planning of flaps to achieve both an aesthetic and functional repair [2,6–8]. In this paper we represent our planning for reconstruction of nostrils, upper and lower lip, chin and cheek in a man with

Treatment of the aging nose

Ronald P. Gruber, MD Nicolas Tabbal, MD Ira D. Papel, MD Stephen E. Metzinger, MD Dr. Gruber: Since this panel is about the aging or senile nose, most of the patients under discussion will be older. This topic is significant because people tend to have weaker tissues as they age. This weakness, coupled with the effect of gravity, results in patients who suffer not only from the aesthetic problems of an elongated nose, but also from problems of airway obstruction. Another factor to consider when treating these patients is that they have different expectations from surgery than younger patients. The first patient is a 68-year-old woman who was not specific about her nasal deformity; she simply wanted an “improved appearance” of her nose (Figure 1). Dr. Tabbal, how would you approach this patient? Would you have reservations about treating her? Figure 1 A-C, This 68-year-old woman would like to improve the appearance of her nose. Dr. Tabbal: What strikes me is that if this patient is looking for ways to rejuvenate or improve her appearance, then she should consider other treatment modalities for facial rejuvenation since her nose is quite benign. She has diminished skin elasticity over the bridge, and the skin of the nasal lobule is quite thick. If she wants to improve her nasal appearance, changes would have to be conservative. Anatomically, this is not a difficult nose to improve. I would use a closed approach, performing a very conservative lowering of her dorsum, shortening the nose, and probably narrowing her nasal base. I would be cautious with the osteotomies because patients in this age group tend to have brittle nasal bones. Dr. Gruber: Dr. Metzinger, when a patient of this age consults with you and wants the nose, and the nose only, improved, does that concern you in terms …

Simultaneous Open Rhinoplasty and Alar Base Excision for Secondary Cases

Simultaneous open rhinoplasty and alar base excision are a very safe procedure for protecting the vascular supply of the nasal dip and the columellar skin in primary cases when surgical dissection is performed below the musculoaponeurotic layer of the nose. Major arteries of the external nose lie above the musculoaponeurotic layer. However, secondary cases may pose increased risks to the blood supply of the nasal tip and columella skin because of the decreased vascular supply and increased scar tissue from the previous rhinoplasty. We studied our secondary cases of simultaneous open rhinoplasty and alar base excision, to assess the real risk for necrosis of the nasal tip and columellar skin. A total of 12 secondary patients (6 men and 6 women) underwent simultaneous open rhinoplasty and alar base excision in the past 3 years. Their average age was 27 years (range, 21-35 years). The average follow-up period was 15 months (range, 1-35 moths). A modified grading system, originally described by Bafaqeeh and Al-Qattan, was used for assessment of the blood supply in the nasal tip and the columellar skin. Satisfactory results were obtained for our patients, with the exception of one case. Grade 3 vascular compromise to the nasal tip and the columella was observed in one case, but the patient healed well with wound care treatment. Simultaneous alar base excision and open rhinoplasty can be performed safely in secondary cases. However some surgical maneuvers such as subcutaneous pocket preparation for the tip graft in closed rhinoplasty and subdermal defatting in the first rhinoplasty as well as previous scarring on the nasal lobule can disrupt the vascular supply of the nasal tip and columella skin. Under these conditions, alar base excision should be deferred and then performed as an isolated excision procedure.

Nasal tip grafting

James W. Fox IV, MD Rollin K. Daniel, MD Stephen W. Perkins, MD Nicolas Tabbal, MD Dr. Fox: Rhinoplasty is the most difficult operation in aesthetic plastic surgery, and I think we would all agree that the most difficult part of the procedure involves the tip of the nose, our subject for this panel. The first patient is a 16-year-old teenager with the familiar complaint, “I hate my nose, it is too big and blobby” (Figure 1). Doctor Tabbal, what would you recommend to this young woman with thick skin? Figure 1 This 16-year-old teenager complains, “I hate my nose; it is too big and too blobby.” Dr. Tabbal: What strikes me is the disproportion in her nasal balance. The nasal lobule is significantly more prominent than the upper half of the nose, which is somewhat narrow. The nasal tip is slightly deviated to the left and is quite heavy looking with effaced lower lateral cartilages. I suspect that the tip volume is primarily related to the quality of the soft tissues rather than the volume or shape of the alar cartilages. In order to achieve the desired tip refinement in this patient, I would rely on a reduction of the volume of the alar cartilages, combined with centralization of the tip and enhancement of the tip defining points through use of the open rhinoplasty approach and tip suture techniques. I see no need for cartilage grafting in this case because tip projection appears to be quite adequate. Dr. Fox: Dr. Perkins, does the width of this patient's nose at the base need to be addressed with regard to getting the tip into balance? Dr. Perkins: Looking at her frontal view, she has fairly wide-set eyes. Her inner canthi are wide enough to accommodate the width of her alar base, which is …

Use of a versatile axial dorsonasal musculocutaneous flap in repair of the nasal lobule.

We present our 17 years of experience in using a sliding axial musculocutaneous flap from the nasal dorsum in the repair of 53 nasal lobular defects (follow-up 3 to 212 months, mean 47.3 months). This flap is a modification of the classic Rintala flap but is based on a greater understanding of surgical anatomy, the biomechanical properties of skin, and physiology of flaps, all of which allow a more aesthetically satisfactory closure of very distal nasal lobular defects. After excising the tumor, two parallel incisions are made along the sides of the nasal dorsum, and flap is raised in the gliding plane deep to the fibromuscular layer of the nose and superficial to the cartilage and bone and then advanced over the defect, which can be as large as the entire nasal lobule. The flap is very reliable (no failure in our series) and easy to perform; furthermore, it is a fast, one-step reconstructive procedure that leaves the scars in areas of natural shadow. This flap makes use of a wide dorsal and glabellar undermining to recruit sufficient skin; it takes advantage of the mild tension exerted by the underlying nasal framework to lengthen the flap reliably without the need for an extra incision or Burow's triangles, as originally described by Rintala. Neither tip rotation nor glabella flattening has ever been found to be a real problem in our series because the flap elongates in a period of 2 to 6 weeks and tip always comes down, provided that the nasal framework is not modified. We believe that the axial musculocutaneous sliding flap has distinct advantages over other alternative local flaps in the repair of lobular nasal defects; moreover, although this simple operation cannot compete with the quality of the aesthetic results achieved by very skilled masters using frontal flaps, it is an easy, quick, one-step procedure that allows acceptable and reliable aesthetic results to be achieved by the majority of surgeons, and it does not harm the precious forehead donor site, which may become essential in case of the need for further reconstruction.

Cartilage grafts for the nasal tip.

Control over nasal tip projection is essential in rhinoplasty. Nasal projection is defined as the length of the perpendicular drawn from the anterior facial plane to the tip-defining point. The nasal lobule shield-type graft, made of autologous cartilage, is one of the most important methods to maintain projection. The graft may also control length, (counter)rotation of the nose and refinement of the tip. The external approach facilitates in-situ suturing and sculpting of the graft. Between 1989 and 1991, 300 patients underwent an external rhinoplasty. In 94 (31%) an autologous graft for the nasal tip was used. The aesthetic result was pleasing to the vast majority of the patients. Nasal tip rigidity resolved in all patients within one year post-operatively. One patient needed revision surgery, because of graft resorption.

The Nasal Tip

New anatomic observations and expanded aesthetics are presented based on an in-depth analysis of 50 patients undergoing primary open rhinoplasty. The alar cartilages can be conceived of as three crura (medial, middle, and lateral), each composed of two segments, plus distinct intervening junction points of aesthetic importance. The classic four-dot tip aesthetics can be expanded and wrapped around the nasal lobule in a three-dimensional fashion. Three nasal tip angles are easily defined (angle of tip rotation, angle of domal definition, and angle of domal divergence) and can be created surgically.

Rhinoplasty

On the basis of over 100 fresh cadaver dissections as well as a review of nasal embryology and development, several important observations can be made regarding surgical anatomy of the nose. Within the bony vault, nasal profile modification consists of two distinct maneuvers: bony hump removal and modification of the nasofrontal groove area. The cartilaginous vault is in reality a unified, winged structure composed of septum and upper lateral cartilages. Within the nasal lobule, a continuous cartilaginous ring exists. The nose itself is covered by a superficial muscular aponenotic system.