Open Rhinoplasty Approach Research Articles

Nasal tip refinement in primary rhinoplasty: The cephalic trim cap graft

Background: Commonly used techniques for achieving nasal tip projection and refinement are adequate for most primary rhinoplasty patients, but they may result in undesirable tip bifidity and visible lower lateral cartilage angularity, especially in patients with thin skin. Objective: We report the use of “like” local tissues, cephalic trim cartilage remnants of the lower lateral cartilages, as invisible tip grafts to soften any angular cartilage edges or tip bifidity. Methods: The cartilaginous framework was exposed by using the open rhinoplasty approach. Lower lateral cartilages were separated from upper lateral cartilages, the caudal septum at the anterior septal angle, and from each other. A cephalic trim was performed as necessary, with the cartilaginous segments preserved for use as a cap graft. Interdomal sutures and transdermal sutures were used either alone or in combination to set the desired tip projection. If tip bifidity was visible through thin nasal tip skin, a cephalic trim cap graft was placed. Results: The procedure can achieve a well-unified nasal tip with no evidence of bifidity, angularity, or cartilage graft visibility. Conclusion: Use of this technique to improve nasal tip projection can avoid undesirable tip bifidity and visible lower lateral cartilage angularity in patients with thin nasal skin. ( Aesthetic Surg J 2002;22:39-45.)

Hemangiomas of the nasal tip.

The treatment of nasal hemangiomas is controversial. Results of nonsurgical treatment methods have been disappointing. In a series of 42 patients with nasal hemangioma, 22 patients underwent early excision. The open rhinoplasty approach proved safe and effective and yielded satisfactory long-term results. The article discusses protocols for evaluation and guidelines for treatment.

Three-dimensional Z-plasty in the correction of the unilateral cleft lip nasal deformity.

Numerous methods have been introduced for correction of the cleft lip nasal deformities, but no single procedure has given sufficiently satisfactory results to provide a surgical standard. Much effort has been put on restoring cartilaginous structures using alar cartilage modification and suspension. But even after the cartilage framework is repositioned well, redundant alar webbing is still unsightly and frequently conspicuous. This paper presents a procedure combining the usual open rhinoplasty technique and three-dimensional Z-plasty in an external approach to remove the alar web and to lengthen the columella at the same time. Open rhinoplasty was performed in 26 consecutive patients with unilateral cleft lip nasal deformity from 1991 to 1996. We used an open rhinoplasty approach, which is a combination of the usual infracartilaginous incision on the noncleft side and a small triangular flap on the cleft side. This external rhinoplasty incision can provide a wide surgical field for the handling of the whole cartilage framework. The three-dimensional Z-plasty utilizing redundant alar skin not only removes the alar web but also helps lengthen the columella and provides soft tissue to the nasal vestibule. This technique is easy, and the postoperative result is very consistent. Our open rhinoplasty approach has several advantages and can be a useful approach in the correction of the unilateral cleft lip nasal deformity.

Three-Dimensional Z-Plasty in the Correction of the Unilateral Cleft Lip Nasal Deformity

Abstract Objective: Numerous methods have been introduced for correction of the cleft lip nasal deformities, but no single procedure has given sufficiently satisfactory results to provide a surgical standard. Much effort has been put on restoring cartilaginous structures using alar cartilage modification and suspension. But even after the cartilage framework is repositioned well, redundant alar webbing is still unsightly and frequently conspicuous. This paper presents a procedure combining the usual open rhinoplasty technique and three-dimensional Z-plasty in an external approach to remove the alar web and to lengthen the columella at the same time. Methods: Open rhinoplasty was performed in 26 consecutive patients with unilateral cleft lip nasal deformity from 1991 to 1996. We used an open rhinoplasty approach, which is a combination of the usual infracartilaginous incision on the noncleft side and a small triangular flap on the cleft side. Results and Conclusions: This external rhinoplasty incision can ...

Extracorporeal septoplasty with paramarginal incision

To reconstruct the airways in the case of serious nasoseptal deviation it is preferable to remove the cartilaginous septum, reshape it, and put it back. This may be done through an open rhinoplasty approach with a transcolumellar scar resulting in wide visual access to the septal structures. As the transcolumellar scar may give problems in some cases, it might be helpful to use an extended paramarginal incision. A traditional open rhinoplasty approach was used in eight patients and the extended paramarginal incision technique in 19 patients. Two of the eight patients who had the open rhinoplasty technique developed unsatisfactory transcolumellar scars. Of the 19 patients who had paramarginal incisions no patient developed late problems. The paramarginal approach was superior to the traditional open rhinoplasty approach despite the slightly better visualisation with open rhinoplasty.

Tratamiento quirúrgico de la disfunción de la válvula nasal mediante la transposición del cartílago triangular

AbstractWe have operated eight patients with nasal obstruction secondary to internal valvulary incompetence. In three of them an alar colapse were associated. Diagnosis was made by anamnesis and clinical exploration. Open rhinoplasty approach was employed. Surgical technique was the transposition of lateral over alar cartilage. In the three patients with alar colapse, a fixation graft of septal cartilage were added to the previous technique. Nasal obstruction and valvular incompetence missapeared in all the patients.

Tertiary and Salvage Rhinoplasties Using the Open Rhinoplasty Approach

This paper reviews the results of 26 tertiary and salvage rhinoplasties, all managed by the open technique. Typically, the endonasal approach has been recommended for these difficult cases because of concerns with skin viability, and the belief that scarred nasal skin will not redrape satisfactorily. Minimal undermining has also been promoted to reduce the risk of graft shifting. Each deformity presented in this review was managed with an open exposure. There were no problems with skin viability or redraping. Cartilage grafts were required less often, and when needed, were sewn precisely into place. Tissue swelling could take 12 to 18 months to settle. This paper reinforces the need for careful preoperative planning. Potential surgical pitfalls are examined.

Secondary rhinoplasty in nasal deformity associated with the unilateral cleft lip.

The secondary nasal deformity of the unilateral cleft lip involves a retrodisplaced dome of the ipsilateral nasal tip, hooding of the alar rim, a secondary alar-columellar web, and other deficiencies. The sliding-flap cheilorhinoplasty effectively corrects these deformities using a laterally based chondrocutaneous flap. We modified this technique by using an open rhinoplasty approach with the laterally based chondrocutaneous sliding flap. Columellar struts and shield grafts were some of the techniques combined with this approach to produce optimal results. In a total of 7 patients, we performed both the original sliding-flap cheilorhinoplasty and the modified open rhinoplasty, which are described and discussed herein. The laterally based sliding-flap cheilorhinoplasty is an effective technique for correcting both the secondary nasal deformity and the lip scar associated with the unilateral cleft lip.

Tertiary and salvage rhinoplasties using the open rhinoplasty approach

Tertiary and salvage rhinoplasties using the open rhinoplasty approach

Treating the hanging columella:No single technique prevails

Over the years, I have utilized a variety of techniques to correct the hanging columella region. These can be separated into management of the caudal septal area, middle crus of the alar cartilage, nasal spine, and columellar tissue. I do not use the open rhinoplasty approach to treat the isolated hanging columella in most cases. I have found that the combination of resection of the caudal septum and two fixation sutures (4-0 PDS) to pull up the hanging columella generally solves the problem. In situations where there is excessive caudal septal tissue, I will resect this to raise the columella. If the caudal septum is twisted, it should be straightened. My …

Late salvage of nasal injuries

Secondary management of patients with posttraumatic injuries remains one of the most difficult management problems for the plastic surgeon. The goal of secondary management of severe nasal trauma is to produce a straight nose that functions properly. Both cosmetic and functional aspects of the nose must be addressed. This requires multiple considerations by the surgeon. An open rhinoplasty approach is most advantageous for treatment of the deviated nose. Wide mobilization of the deviated structures with maintenance of the mucoperichondrial attachments is an important principle. All extrinsic and intrinsic forces causing the nasal deviation must be released. Precise nasal osteotomy planning is required, as dictated by the anatomic deformity. Extensive septal modification is required including resection, morsalization, scoring, septal flaps, and suture techniques. The judicous use of spreader grafts is recommended to improve both the aesthetic and functional result for the deviated nose. This algorithm is reviewed in detail, and we have found it to reliably produce predictable results in the management of the deviated nose.

The infradome graft: a new technique to improve dome reshaping in rhinoplasty.

As the open approach rhinoplasty has gained popularity, newer techniques for aggressive reshaping of the alar cartilage have become available. The most effective way to increase alar dome definition is the dome plication technique described by Daniel, which places a horizontal mattress suture, applied with incremental tension, between the medial and lateral crura. The disadvantage of this technique is that it can produce either overtightening or distortion of the cartilage, with excessive pinching of the nasal tip. Also, as it relies on a single nylon suture to fight against the cartilage's shape memory, it has the potential for relapse. The present article describes a new technique to overcome these problems. It consists of placing two parallel strips prepared from the resected alar cartilage excess under the domes. These grafted cartilages block the plication suture, thus avoiding the risk of excessive pinching of the domes and ensuring symmetry and stability. Using this technique, I have consistently obtained a nasal tip that is well defined over the nasal dorsum line in my patients.

Rhinoplasty in cleft lip/palate deformity

Rhinoplasty for the deformity of the nose, associated with cleft lip/palate, is a difficult procedure. Proper aesthetic consideration is vital to its success. It principally involves correction of the lower lateral cartilages and the septum. The autogenous septal cartilage pieces are used for minor adjustment and augmentation for elevation of the depressed segment of nasal tip. Open rhinoplasty approach has significantly simplified the procedure. (Rethi 1956, Goodman 1974). It is a good approach since it offers a direct and wide view of the whole nasal skeleton and is an easily teachable and learnable one. CASE REPORT

Elliptical horizontal excision and repair of alar cartilage in open-approach rhinoplasty to correct cartilaginous tip deformities.

Correction of nasal tip deformities, especially bulbous tip deformities, has improved greatly with the advancement of open-approach rhinoplasty. Bulbous and double-dome deformities of the nasal tip are more often cartilaginous, rather than fibrous, in nature. Therefore, direct alterations of the cartilage are necessary to achieve the desired effect. In the past, these alterations were accomplished by resection of the cephalic part of the lateral crura of the lower lateral cartilage and, less commonly, by resection of the caudal ends of the lateral crura. For the past several years, we have used elliptical excision of the central segment of the lower lateral cartilage in a horizontal direction. The upper and lower edges of the remaining cartilage are repaired with 5-0 nylon sutures. This procedure removes the most protruding and bulbous portion of the lateral crura, and the cephalic and caudal portions that remain are sutured together to form a flatter and more narrow lateral crura. It changes the bulge of the dome where a change is necessary, at the top. It also preserves the anatomically intricate relationship of the junctions of the upper and lower lateral cartilage. There are no free or loose edges of cartilage to warp or deform during the healing process. Satisfactory, long-lasting clinical results can be achieved consistently.

Endoscopic transseptal transsphenoidal surgery for pituitary tumors.

Transseptal transsphenoidal surgery of pituitary tumors is a well-established surgical technique. The sublabial approach and the open rhinoplasty approach are most commonly used. In both cases, the surgical avenue is along the entire length of the nasal septum, removing both nasal cartilage and the vomer. Septal perforations and upper dental anesthesia are frequent complications of the standard approaches. We describe our initial experience in using the nasal endoscope for the first stage of the operation. A nasal endoscope was used to open the anterior wall of the sphenoid sinus. Our initial incision was in the posterior third of the septum, removing only the vomer. After the sphenoid sinus was opened, we inserted a speculum and proceeded with the operation with an operating microscope. After the speculum was in place, it was easier to proceed with the microscope, which allows binocular vision and bimanual operation. The procedure was used for our most recent 14 consecutive patients with pituitary adenomas. No complications related to the approach were encountered for any of the patients in follow-up monitoring. The endoscopic transseptal approach to the sphenoid sinus for pituitary surgery was found to be easy, time-saving, and without septal or sublabial complications.

Endoscopic Transseptal Transsphenoidal Surgery for Pituitary Tumors

Transseptal transsphenoidal surgery of pituitary tumors is a well-established surgical technique. The sublabial approach and the open rhinoplasty approach are most commonly used. In both cases, the surgical avenue is along the entire length of the nasal septum, removing both nasal cartilage and the vomer. Septal perforations and upper dental anesthesia are frequent complications of the standard approaches. We describe our initial experience in using the nasal endoscope for the first stage of the operation. A nasal endoscope was used to open the anterior wall of the sphenoid sinus. Our initial incision was in the posterior third of the septum, removing only the vomer. After the sphenoid sinus was opened, we inserted a speculum and proceeded with the operation with an operating microscope. After the speculum was in place, it was easier to proceed with the microscope, which allows binocular vision and bimanual operation. The procedure was used for our most recent 14 consecutive patients with pituitary adenomas. No complications related to the approach were encountered for any of the patients in follow-up monitoring. The endoscopic transseptal approach to the sphenoid sinus for pituitary surgery was found to be easy, time-saving, and without septal or sublabial complications.

Surgery for Nasal Valve Stenosis

Nasal valve is now regarded slit-like opening between the caudal end of the upper lateral cartilage and the septum. Because of wider nasal valve angle than Caucasians, we have fewer chances to experience patients with stenotic nasal valve. However, with careful history taking and Cottle test, we can recognize patients with nasal obstruction due to nasal valve stenosis. They require surgical correction. Surgical intervention was directed toward reconstruction of normal anatomic relationships between upper-and lower lateral cartilage and between the former and septal cartilage. This is usually achieved by widening the nasal valve angle and preventing collapsibility. There are two methods of approach to the nasal valve ; transnostril approach and open rhinoplasty.1) Transnostril approach Retracting the ala by means of the blunt retractor, the lower border of the upper lateral cartilage is identified. Incision of the skin parallet to the lower end of the upper lateral cartilage at lmm distance (intercartilagenous incision). The incision is continued just beyond the angle of the valve. Dissection of the caudal end of the cartilage is performed by elevating the mucoperichondrium with sharp, slightly-curved scissors. A strip of cartilage is resected from the caudal end of the upper lateral cartilage.2) open rhinoplasty approach Notched transcolumellar incision at the level of the midcolumella. This incision is connected to bilateral columellar marginal incisions that is usually placed lmm behind the rim of the columella. By using scissors, the skin overlying the medial crura is dissected. The flap is carefully elevated up from the underlying medial crura. Then the flap is elevated off of the surface of the lower lateral cartilage. Decortication is accomplished with dissection of soft tissue form the region of the anterior septal angle. Caudal margin of the upper lateral cartilage is resected or fixed on the lower lateral cartilage.

Structural grafting of the crooked nose deformity

Educational objectives: To analyze crooked nose deformities and determine effective technique for correction and to gain access to the nasal septum by the open rhinoplasty approach and use spreader grafts, sandwich grafts, and septal reconstruction to correct the crooked nose deformity.

Advanced Open Structure Rhinoplasty

Educational objectives: To use open rhinoplasty approach to gain exposure to correct deformities seen in secondary rhinoplasty, posttraumatic deformities, and reconstructive cases, and to use structural grafts to correct aesthetic and functional deformities of the nose.

Management of the middle nasal vault in rhinoplasty

The incidence of aesthetic and functional complications of rhinoplasty can be decreased by preserving supportstructures of the nose. This is particularly important in patients at high risk for collapse of the middle nasal vault (cartilaginous nasal vault). Aggressive surgical manipulation of the upper lateral cartilages can result in excessive narrowing of the middle vault and collapse of the internal nasal valve. Spreader grafts can be used to provide appropriate width to the middle vault and preserve nasal valve function. This paper will discuss indications and technique for application of spreader grafts using the open rhinoplasty approach. Spreader grafts can be used in high risk patients with short nasal bones, long weak upper lateral cartilages, thin skin, and narrow projecting nasal vault. These patients are at higher risk for excessive narrowing of the middle vault (inferomedial collapse of upper lateral cartilages) because of loss of medial support after hump removal. Spreader grafts will support the lateral nasal wall, preserve nasal width, and prevent deformity. Spreader grafts can also be used to add width to the cartilaginous vault in disproportioned noses that have an excessively narrow middle vault and broad nasal tip. This maneuver will allow the surgeon to perform conservative narrowing of the nasal tip and prevent deformity or compromise of nasal function. Spreader grafts can be used in combination with lateral crural grafts or alar batten grafts to correct secondary deformities of the internal and/or external nasal valve. Conservative reduction and thoughtful augmentation in rhinoplasty will preserve nasal support and function with improved long-term results.