Nasal Scarring Research Articles

Nasal columella reconstruction using philtrum advancement flap: a case report of treatment of nasal stenosis

BackgroundNasal columella reconstruction is a challenging procedure, and the main goal is to maintain function as well as a satisfactory aesthetic outcome. Several surgical techniques have been described for the reconstruction of nasal columella. However, there is a paucity of literature on these techniques in our environment, and the use of superiorly based philtrum advancement flaps is extremely rare in African literature.Case presentationA 60-year-old man presented with nasal obstruction and nasal deformity following facial trauma 6 months prior to presentation. Examination revealed bilateral stenosed nasal cavities and a very short columella with a healed nasal scar. The diagnosis of nasal stenosis was made. Intra-operatively, a superiorly based philtrum advancement flap was designed and elevated, granulation tissues in the nasal cavities were excised, the septum was repositioned, the base of the flap was sutured at the midline of the floor of the nose, and the donor site was approximated. A bilateral nasal stent was applied for 4 weeks. Postoperatively, the recipient and donor sites healed completely with an aesthetically acceptable appearance, and the patient was satisfied with the outcome.ConclusionNasal columellar reconstruction is a complex procedure. The superiorly based philtrum advancement flap is a simple and aesthetically acceptable method of treating nasal stenosis. This method demonstrated an adequate nasal airway and a good cosmetic appearance.

Combined CO2 and dye laser technique in the treatment of outcomes due to flap necrosis after surgery for basal cell carcinoma on the nose

AbstractBackground and ObjectiveBasal cell carcinoma (BCC) is the most frequent cutaneous cancer worldwide, and the nasal area is the most commonly affected region. Skin flaps are usually performed to achieve radical results, but various adverse events often occur. The necrosis of the skin flap is one of the most frequently observed, resulting in scars and anti‐aesthetic outcomes. Ablative and non‐ablative lasers have been proposed to improve scars resulting from surgical failure and skin flap necrosis.Study Design/Materials and MethodsThis study aims to evaluate a new laser protocol combining ablative CO2‐laser with flashlamp pulsed dye laser for the treatment of nasal scars resulting from the necrosis of flap that occurred after surgery. Twelve patients were enrolled in the study, and a total of five laser sessions were planned, spaced from 14 days to 1 month apart.ResultsSeven out of 12 patients underwent all the five laser sessions planned, while 5/12 patients achieved optimal cosmetic results within the fourth session. Eighty percent of the patients reported good/optimal cosmetic results, and no significant side effects were observed during the study.ConclusionCombining fractionated CO2 laser with flashlamp pulsed dye laser represents a new effective modality for treating skin flap necrosis after BBC removal, representing a valid alternative to other surgical procedures.

Concurrent Excision of Dorsal Nasal Scars and Reduction Rhinoplasty: A Retrospective Cross-sectional Study.

Background:Skin lesions and traumas can affect the skin by leaving scars. The purpose of this study was evaluating the results of a new technique in reconstructive surgery of scars on the nose. In this technique, extra skin remaining from reduction rhinoplasty is applied to the defect remained from removing the scar.Methods:This is a retrospective cross-sectional study performed on 33 patients who underwent reduction rhinoplasty from 2013 to 2018 due to scars on the dorsal nasal skin. Five sets of standards, criteria, and questionnaires were used to evaluate the cosmetic outcomes, scars, and nasal function. These included the Cakir concept, visual analogue scale, patient reported outcome measurement, Stony Brook scar evaluation scale, and sino-nasal outcome test-22.Results:According to the surface polygon concept, or Cakir concept, the number of affected polygons due to scars decreased in all included patients (P < 0.05). In addition, constant improvement in patients’ satisfaction, based on patient reported outcome measurement (P < 0.001) and visual analogue scale (P ≤ 0.05), as well as physicians’ satisfaction, based on Stony Brook scar evaluation scale, were determined. Furthermore, evaluating the patients’ breathing, based on sino-nasal outcome test-22 criteria (P < 0.09), indicated no adverse effects.Conclusion:Excision of scars from dorsal nasal skin and conducting rhinoplasty surgery from the same access can be considered an option for reconstructing nasal scars.

Treatment of nasal depressed scars using micro-plasma radiofrequency technology combined with subcision.

The nose is located in the middle of the face; therefore, nasal scarring will bring a significant psychological impact on patients. Although there are many treatment methods for depressed scars, these methods have varying degrees of efficacy and all carry certain adverse effects. A better treatment method is urgent to be found. In this study, the effect of micro-plasma radiofrequency technology combined with subcision to treat nasal depressed scars is evaluated. 18 Chinese patients with nasal depressed scars participated in this study. All patients received one session of micro-plasma radiofrequency treatment first. 2months later, subcision combined with micro-plasma radiofrequency technology was performed on them at 6-month intervals, and a total of 2sessions of combined treatment were performed. Goodman and Baron Scale was used to evaluate nasal scars before treatment and 6months after the final session. All 18 patients in this study had Grade 4 nasal scars before treatment. 6months after the end of treatment, 13 patients (72.2%) showed excellent or near total improvement, and 5 patients (27.8%) showed marked improvement. No adverse side effects were observed during treatment. Patient self-evaluation indicated that all patients were satisfied with the cosmetic outcomes. In this study, we explored a new treatment method for nasal depressed scars. We used micro-plasma radiofrequency technology combined with subcision to treat nasal depressed scars and obtained relatively satisfactory results with no adverse effects.

Upper respiratory tract disease and associated diagnostic tests of mycoplasmosis in Alabama populations of Gopher tortoises, Gopherus polyphemus.

Upper respiratory tract disease (URTD) in North American tortoises (Gopherus) has been the focus of numerous laboratory and field investigations, yet the prevalence and importance of this disease remains unclear across many tortoise populations. Furthermore, much research has been focused on understanding diagnostic biomarkers of two known agents of URTD, Mycoplasma agassizii and Mycoplasma testudineum, yet the reliability and importance of these diagnostic biomarkers across populations is unclear. Gopher Tortoises (Gopherus polyphemus) have experienced significant declines and are currently protected range wide. Geographically, Alabama represents an important connection for Gopher Tortoise populations between the core and periphery of this species’ distribution. Herein, we systematically sampled 197 Gopher Tortoises for URTD across seven sites in south-central and south-eastern Alabama. Plasma samples were assayed for antibodies to M. agassizii and M. testudineum; nasal lavage samples were assayed for the presence of viable pathogens as well as pathogen DNA. Lastly, animals were scored for the presence of external symptoms and nasal scarring consistent with URTD. External symptoms of URTD were present in G. polyphemus in all sites sampled in Alabama. There was no relationship between active symptoms of URTD and Mycoplasma antibodies, however the presence of URTD nasal scarring was positively related to M. agassizii antibodies (P = 0.032). For a single site that was sampled in three sequential years, seroprevalence to M. agassizii significantly varied among years (P < 0.0001). Mycoplasma agassizii DNA was isolated from four of the seven sites using quantitative PCR, yet none of the samples were culture positive for either of the pathogens. An analysis of disease status and condition indicated that there was a significant, positive relationship between the severity of URTD symptoms and relative body mass (P < 0.05). This study highlights the need for continued monitoring of disease in wild populations. Specifically, focus must be placed on identifying other likely pathogens and relevant biomarkers that may be important drivers of URTD in North American tortoises. Special consideration should be given to environmental contexts that may render wild populations more susceptible to disease.

Large Nasal Defects with Exposed Cartilage: The Folded Transposition Flap as an Innovative Alternative to the Paramedian Forehead Flap

Background: Skin cancer removal surgery involving the tip or dorsum of the nose often results in large-sized defects with exposure of cartilage. In such cases, the paramedian forehead flap is a frequently used reconstruction technique; however, this method is complex and can result in a cosmetically unsatisfying outcome. Objective: To describe the folded transposition flap as an aesthetically pleasing alternative to the paramedian forehead flap for large nasal defects with exposed cartilage. Methods: The folded transposition flap is a 2-stage surgical modification of the transposition flap. In the first stage, an overlong axial cheek pedicle is used to cover the defect. In the second stage, the flap is thinned and the nasal scars are revised. Results: All 4 patients experienced aesthetically pleasing results. Conclusion: The folded transposition flap is an alternative for reconstructing large surgical defects of the nasal tip or distal dorsum of the nose.

Reconstructive Approaches to Nasal Defects

Nasal reconstruction is commonly performed for treatment of defects arising from excision of nonmelanoma skin cancers, although other tumors, trauma, or infection may also result in significant nasal deformities necessitating corrective surgery. Patients being evaluated for nasal reconstruction should have a functional assessment of airflow through both the internal and external nasal valves to determine the need for reconstructive maneuvers that will maintain or improve the nasal airway. Aesthetic considerations relate to which nasal subunits are missing and how local, regional, and sometimes free tissue transfer can be used to optimize the final appearance of the nose. Reconstruction must incorporate a plan for reestablishing nasal lining, support, and cover depending on which elements are missing. Postoperative considerations include the need for nasal splints and interventions to optimize nasal scarring and contour such as scar massage, steroid injection, and laser treatments. Patients who are not good candidates for autologous nasal reconstruction may be considered for prosthetic reconstruction. This review contains 13 figures and 67 references Key words: Nasal reconstruction, Nasal airway, Mohs surgery, Skin cancer, Nasal aesthetic subunits, Facial flaps, Skin graft, Forehead flap, Nasal cover, Nasal lining, Nasal support, Prosthetic rehabilitation

Reconstructive Approaches to Nasal Defects

Nasal reconstruction is commonly performed for treatment of defects arising from excision of nonmelanoma skin cancers, although other tumors, trauma, or infection may also result in significant nasal deformities necessitating corrective surgery. Patients being evaluated for nasal reconstruction should have a functional assessment of airflow through both the internal and external nasal valves to determine the need for reconstructive maneuvers that will maintain or improve the nasal airway. Aesthetic considerations relate to which nasal subunits are missing and how local, regional, and sometimes free tissue transfer can be used to optimize the final appearance of the nose. Reconstruction must incorporate a plan for reestablishing nasal lining, support, and cover depending on which elements are missing. Postoperative considerations include the need for nasal splints and interventions to optimize nasal scarring and contour such as scar massage, steroid injection, and laser treatments. Patients who are not good candidates for autologous nasal reconstruction may be considered for prosthetic reconstruction. This review contains 13 figures and 67 references Key words: Nasal reconstruction, Nasal airway, Mohs surgery, Skin cancer, Nasal aesthetic subunits, Facial flaps, Skin graft, Forehead flap, Nasal cover, Nasal lining, Nasal support, Prosthetic rehabilitation

Closure of nasal septal perforations with a polydioxanone plate and temporoparietal fascia in a closed approach.

Septal perforation closure is still often invasive and complex, with relatively low closure rates. We aimed to provide the first results of a case series of 20 patients with nasal septal perforations who underwent septal perforation repair by both an open and a minimally invasive technique by using a graft that consisted of temporoparietal fascia and a polydioxanone (PDS) plate without mucosal flaps. Between 2014 and 2016, we tested, for the first time, the feasibility of the insertion of this graft via a hemitransfixion incision at our institution. The rationale for the closed approach was to avoid any visible nasal scars. We reported our results of both approaches. The septal perforations were closed by insertion of a graft, which consisted of a 0.25-mm PDS flexible plate enveloped by temporoparietal fascia, into the perforation. The insertion of the graft was performed either via a columellar incision (open approach) or via a cosmetically advantageous hemitransfixion incision (closed approach) in an underlay technique. No attempts were made to close the perforation by mucosal flap rotation and/or advancement. Protective silastic sheeting to both sides of the perforation provided fixation to the graft while natural mucosal healing occurred over the perforation in the course of 3 to 8 weeks. Eighteen of 20 perforations were closed by mucosa at the last follow-up. The mean follow-up was 8.7 months. Thirteen patients had surgery via the closed approach. We showed, for the first time, that the insertion of a graft that consisted of a PDS flexible plate enveloped in temporoparietal fascia via a hemitransfixion incision was feasible and resulted in complete mucosal closure of nasal septal perforations in most patients. By performing the hemitransfixion incision, we avoided any visible nasal scars.

Case Report: Revision of a Nasal Scar after a Vehicle Accident

Case Report: Revision of a Nasal Scar after a Vehicle Accident

Case Report: Revision of a Nasal Scar after a Vehicle Accident

Case Report: Revision of a Nasal Scar after a Vehicle Accident

Adjuncts to Improve Nasal Reconstruction Results.

The final cosmetic appearance of nasal reconstruction scars is of paramount importance to both the patient and surgeon. Ideal postreconstruction nasal scars are flat and indistinguishable from surrounding skin. Unfortunately, even with meticulous surgical execution, nasal scars can occasionally be suboptimal. Abnormal fibroblast response can lead to hypertrophic nasal scars, and excessive angiogenesis may lead to telangiectasias or an erythematous scar. Imperfect surgical closure or poor postoperative management can lead to surgical outcomes with step-offs, depressions, suture marks, or dyspigmentation. Aesthetically unacceptable nasal scars can cause pruritus, tenderness, pain, sleep disturbance, and anxiety and depression in postsurgical patients. Fortunately, there are several minimally invasive or noninvasive techniques that allow for enhancement and improvement of cosmetic results with minimal risk and associated downtime. This article provides an overview of adjuncts to improve nasal reconstruction with a focus on techniques to be used in the postoperative period. Armed with an understanding of relevant available therapies, skillful surgeons may drastically improve the final cosmesis and outcome of nasal reconstruction scars.

Treatment of nasal microcystic adnexal carcinoma with an expanded rotational forehead skin flap: A case report and review of the literature.

Microcystic adnexal carcinoma (MAC) is a rare and locally aggressive adenocarcinoma with low-grade malignancy. The present study describes the first reported case and treatment of a Chinese male with a MAC located on the nasal dorsum and nosewing. A 44-year-old man presented with a nasal deformity caused by local repeated infections following an accidental injury to the nose 20 years previously. The nose had been injured by a brick, and treatment at a local hospital 12 years previously had resulted in a nasal scar and a gradually enlarging mass. A physical examination revealed a hypertrophic deformity of the nose and an indurated scar plaque, measuring 2.0×2.0 cm, on the nasal dorsum and nosewing. Microscopic examination revealed a tumor consisting of solid cell nests and a cystic structure with a capsular space. In addition, ductal cells of an adnexal cell origin were visible in the outer epithelium. The medial portion exhibited a microductal structure and invasion of deeper tissues without evident atypia. The tumor cells presented normal nuclear to cytoplasmic ratios and minimal mitotic activity. Pathological examination verified that the tumor was a MAC of low-grade malignancy. A complete surgical resection was performed via Mohs micrographic surgery (MMS), and reconstruction was achieved using an expanded rotational forehead skin flap. No tumor recurrence was detected after a three-year follow-up period. Therefore, for effective treatment of similar MAC cases, complete surgical resection using MMS is recommended, and successful reconstruction may be achieved using an expanded skin flap.

CPAS: Surgical approach with combined sublabial bone resection and inferior turbinate reduction without stents.

Congenital pyriform aperture stenosis (CPAS) is a form of nasal obstruction caused by congenital narrowing of the maxilla at the medial processes. Traditionally, surgical correction involves a sublabial approach with subperiosteal dissection, widening of the aperture by drilling, and the use of nasal stents postoperatively. Although this approach may lead to symptomatic improvement, it alone may fail to provide a patent airway secondary to unaddressed posterior narrowing. Additionally, the use of stents is problematic because they are prone to clogging and can cause internal nasal scarring and septal or alar necrosis. We present the surgical management of this condition in six patients using a novel approach that aims to correct these limitations by including both the traditional sublabial procedure and an endonasal reduction of the inferior turbinates, without the use of stents postoperatively. Retrospective chart review. Review of the medical records of six consecutive patients aged 2 weeks to 7 months, who underwent repair of CPAS via a sublabial ostectomy and endonasal inferior turbinate reduction from 2009 to 2012. All six patients were clear of airway obstruction postoperatively and at follow-up. This is an alternative approach that leads to symptomatic improvement for CPAS patients without the morbidity associated with stent use. 4.

An assessment tool for babies requiring nasal CPAP and high flow

Southmead Neonatal Unit is a level 3 tertiary Unit. From 1st January 2013 to 31st April 2014 there were 3112 days of nasal CPAP, of which 353 babies received nasal CPAP via Bubble CPAP using the Fisher and Paykell model, Sipap using the Viasys model or via the Drager model. Nasal CPAP is an effective treatment modality for neonates with RDS and respiratory disease [1]. Nasal CPAP devices have the potential to cause nasal excoriation and scarring if inappropriately applied or infrequently monitored [2]. Care givers providing close observations, i.e. hourly assessment of the infant’s nares have the unique opportunity to identify and assess the infants’ nares [3]. Nurses currently care for babies requiring nasal CPAP work through a CPAP competency. The Practice Development team and the Respiratory team at Southmead have devised a set of guidelines which includes a CPAP competency and a CPAP care plan. In accordance with the Department of Health’s tool kit for High Quality Neonatal Services staff undergo training and achieve these competencies [4]. Each manufacturer provides a tool or template with directions for measuring the baby’s nares and head to determine the appropriate size prongs/ mask and hat. One main challenge is obtaining a well-fitting hat and prongs/mask to maintain airway pressure. The following components need to be examined to

Secondary Cleft Rhinoplasty

The cleft nasal deformity seen in patients with unilateral and bilateral cleft lip presents a formidable challenge for the facial plastic surgeon. The underlying anatomic deformities combined with scarring from previous procedures make secondary cleft rhinoplasty a difficult procedure for even the most experienced surgeons. Numerous techniques for secondary cleft rhinoplasty have been described in the literature over the past several decades, yet the lack of wide adoption of any given technique highlights the great variability seen with this problem. Regardless, the fundamental goals of achieving nasal symmetry with definition of the nasal base and tip, correction of nasal airway obstruction, and repair of nasal scarring or webbing have driven the progressive evolution of techniques developed to correct various aspects of the cleft nasal deformity. Despite the number of techniques that have been published, very few studies have looked specifically at outcomes in secondary cleft rhinoplasty, and further work is needed in this area. In this article, we will review anatomy of the cleft nasal deformity, repair strategies and timing, surgical techniques for both unilateral and bilateral cleft nasal deformity, and outcomes for secondary cleft rhinoplasty.

The effect of nasal introduction of anaesthetic in adults undergoing Fibreoptic Endoscopic Evaluation of Swallowing (FEES): A systematic review protocol

The primary objective of this systematic review is to identify and synthesise the best available evidence on the effect of anaesthetic on the physiological aspects of swallowing (rate, strength, and risk of laryngeal penetration or aspiration) as well as client pain and/or discomfort in adults undergoing Fibreoptic Endoscopic Evaluation of Swallowing (FEES). This procedure is also described as Fibreoptic Endoscopic Evaluation of Swallowing with Sensory testing (FEESS or FEESST) and Videoendoscopic Evaluation of Dysphagia (VEED). Inclusion criteria Types of participants This review will consider adults (defined for the purposes of this review as being 16 years and over), regardless of gender or reason for undergoing the FEES procedure. Paediatric patients will not be considered for this review due to the challenges of conducting this procedure on this patient group including the size of the nasal passages and nasopharynx, and poor tolerance of the procedure. Participants must have no known co-morbidities that might affect the outcomes of interest (e.g. nasal surgery, deviated nasal septum, traumatic brain injury, reaction to anaesthetic, known allergies, hypertrophic turbinate, nasal scars, craniofacial disorders) Only studies involving patient clients/participants, not volunteers, will be included, as this best reflects the population seen in clinical practice. Types of intervention(s) The intervention of interest for this review is the topical application of an anaesthetic prior to conducting the FEES procedure. Studies comparing swallow function/competency during a FEES procedure, with and without anaesthetic, will be considered for inclusion in the review. With respect to the kind of anaesthetic used, only studies that examined the effects of nasal introduction of anaesthetic (spray or direct application to the nasal mucosa), regardless of dosage, anaesthetic, type of anaesthetic, timing of introduction of the anaesthetic and who applies the anaesthetic, will be included, as this best reflects clinical practice. Comparators are anticipated to include placebo, lubricant or vasoconstrictor only. Types of outcomes The main outcomes of interest for this review are measures of physiological aspects of swallow function and measures of client pain and/or discomfort. Measures of physiological aspects of swallow function Studies where objective measures (such as videofluoroscopy) of swallow function/competency have been utilised will be preferentially sought. The review will however consider studies that have utilised subjective measures, such as validated swallow rating scales. These features of swallowing are regularly evaluated to determine dysphagia. Speech pathologists routinely evaluate normal and abnormal function in these parameters. Measurement will be the clinicians’ evaluations of evidence of dysphagia. Measurement might also include simultaneous videofluoroscopic evaluation, and inter-rater reliability evaluation. Client pain and/or discomfort Studies that report any measures of client discomfort and/or pain related to undergoing a FEES procedure either with or without an anaesthetic will be considered for inclusion in this review. Anticipated outcome measures include but are not limited to: self-reported pain/discomfort (such as via visual analogue scales), behavioural observation by clinician, pain/discomfort, patient anxiety measured by index scales, visual analogue score sheets, questionnaires.

Patient Complaints With Primary Versus Revision Rhinoplasty: Analysis and Practice Implications

Rhinoplasty patients often present with specific concerns and are frequently exacting in their demands and expectations of the surgical experience. The authors assess the presenting complaints expressed during the rhinoplasty consultation process and compare the presentations of primary versus revision rhinoplasty patients. A retrospective review of 400 consecutive rhinoplasty patients was performed. Demographic information and patient concerns regarding nasal appearance and function were recorded. Complaint frequencies (as well as rank order) were compared between primary and revision patients. Statistically significant associations were compared in more detail through logistic regression models. Primary rhinoplasty patients were significantly more likely to cite "too large" and "dorsal hump" as motivating concerns. Conversely, revision rhinoplasty patients were far more likely to cite concern regarding a "crooked nose," "tip asymmetry," "wide or large nostrils," "dorsal sloop," and "columellar show." Revision rhinoplasty patients also complained of issues such as "alar retraction," "pointy tip," and "nasal scarring," which were almost negligible in frequency in the primary rhinoplasty group. Patients presenting for primary rhinoplasty commonly seek a smaller, more refined nasal appearance. Patients with prior rhinoplasty operations are far more likely to raise concern regarding crookedness or asymmetries. By comparing the presentations of primary and revision rhinoplasty patients-and delineating the common indications for revision operations-novice rhinoplasty surgeons may be able to avoid certain pitfalls at the outset, thereby reducing their revision rates. The data may also assist surgeons in developing a more targeted approach to the consultation process in the revision setting.

Nasal Mucosal Involvement in Behcet Disease: A Study of its Incidence and Characteristics in 400 Patients

Behçet disease is a multisystem vasculitis characterized by mucosal aphthosis, primarily in the oral and genital mucosa. Only a few cases of involvement of the nasal mucosa have been reported in the literature, and its true prevalence is not known. We conducted a cross-sectional study of 400 consecutively presenting patients with confirmed Behçet disease (according to classification-tree criteria) to determine the incidence of nasal mucosal involvement, to identify its particular characteristics, and to determine if there are any statistically significant differences in clinical and paraclinical parameters between Behçet disease patients with nasal involvement and those without. To the best of our knowledge, this is the first systematic evaluation of nasal involvement in patients with Behçet disease to be published in the literature. Data analysis was performed with Statistical Package for the Social Sciences software (SPSS), and a confidence interval (CI) at 95% was calculated for each finding. Involvement of the nasal mucosa was seen in 31 of the 400 patients (7.8%; CI: 5.1 to 10.5). Among those 31 patients, the most common nasal symptom was dysosmia, which was seen in 15 patients (3.8% of the total population; CI: 1.9 to 5.7); other nasal symptoms included obstruction in 10 patients (unilateral in 9), ulcers in 2, pain in 2, and a burning sensation and discharge in 1 each. No patient reported a history of epistaxis or nasal itching. Abnormal signs were present in only 16 patients (4.0%; CI: 2.1 to 5.9); they included nasal cartilage deformity in 6, unilateral nasal obstruction in 4, postnasal discharge in 3, nonaphthous ulcer in 3, and crusted ulcer in 2 (2 patients each had 2 abnormal signs). No case of aphthous ulcer, nasal discharge, nasal scar or deformity, septal perforation, or nodular or granulomatous cartilage lesion was found. There were no statistically significant differences in clinical and paraclinical disease manifestations between those patients who had nasal mucosal involvement and those who did not.

The upper buccal sulcus approach, an alternative for post-trauma rhinoplasty

We suggest that it is possible to correct the stigmata of the post-traumatic nasal deformity by means of an upper buccal sulcus approach alone. This approach is demonstrated in a series of ten cadaveric subjects for the correction of nasal skeletal deviation or bossing. Furthermore, the technique, which avoids internal nasal scarring and violation of the internal nasal valve, has been successfully employed in four patients with a minimum of 9 months follow-up. We suggest that it is possible to conserve the internal nasal valve and avoid problems of nasal tip retractions using this approach in selected cases.