Rhinoplasty Techniques Research Articles

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 .

Introducing a Favourite Tip Definition and Projection with Tripod Suture in Rhinoplasty.

Surgical manipulation of the lower lateral cartilages of nasal tip could cause subtle but significant responses to the manipulation. The suture-techniques almost always offer a reliable and dramatic method of tip reshaping without a need to break or interrupt the alar rim strip or even adding tip graft. The aim of this study was to describe and assess outcomes of a new suture technique in rhinoplasty by using cephalic dome septal rotation suture for better tip definition. All consecutive women (62 women) who attended our centre with nasal tip drooping and some degree of columellar retraction, underwent this technique from January 2005 to September 2009. Their ages ranged from 17 to 32 years old. Fifty one primary open and 11 secondary open rhinoplasties were performed using the conventional techniques and then the new suture technique was applied before closing the incisions on each patient. The patients were followed-up from 22 to 72 months (mean = 52.3). The projection and rotation was satisfactory in all patients and the final results persisted with only minimal changes over time. It is important to say that this new suture is different from 'tip rotation suture' that was described by Tebbets. Our suture maintains the favorite tip definition with slight dorsal tip inclination. Indeed, it causes a two-point definition as the columellar lobular angle and the supra tip break definition. In addition, long-term follow-up has shown that this new suture (i.e., cephalic dome-septal rotation suture) is able to maintain optimal position of the nasal tip projection and definition.

Cleft Rhinoplasty: A Surgical Technique

ABSTRACTNasal deformity, a common occurrence in unilateral and bilateral cleft lip and cleft palate patients, is a formidable challenge for the cleft surgeon. The underlying abnormal anatomy, aggravated by tissue scarring and loss of facial planes after primary procedures, makes secondary rhinoplasty a difficult procedure for even the most experienced. Over the past years, numerous techniques for secondary cleft rhinoplasty have been described in literature. Regardless of the technique adopted, the fundamental goal of cleft rhinoplasty is to achieve a nose that would be esthetically accepted in society as well as functionally accepted by the patient. The correction of nasal deformity can be performed with a closed or an open technique. This article highlights the open technique used for secondary rhinoplasty for a challenging case of unilateral cleft lip nasal deformity in an adult patient.How to cite this articleMehrotra V, Natarajan S, Deshpande G, Merchant R. Cleft Rhinoplasty: A Surgical Technique. J Contemp Dent 2017;7(3):188-193.

Nasal Tip Dermoid Sinus Cyst Excision by Open Rhinoplasty Technique

AbstractNasal dermoid sinus cysts are uncommon congenital anomalies, presenting either as cysts or sinuses with varied presentation at birth, childhood, or even adulthood. A midline nasal pit, fistula, or infected mass may be located anywhere from the glabella to the nasal columella. Preoperative radiological investigation with CT (computed tomography) and MRI (magnetic resonance imaging) scans is mandatory to rule out intracranial extension. Complete excision of the cyst along with its tract is the only definitive therapeutic modality. We present a case of nasal dermoid sinus cyst in a 3-year-old male child who underwent excision by open rhinoplasty approach.

Aesthetic Rhinoplasty as a Surface-Contour Operation: From Analysis to Surgery—Personal Concepts

Numerous beautiful rhinoplasty results have been created by closed rhinoplasty techniques over the past 100 years. This operation was mainly a "reduction" surgery. Overaggressive reduction rhinoplasty is not a hallmark of the closed approach per se, but represents the result of inappropriate aesthetic appraisal, inadequate technical execution, or lack of sound anatomical understanding. Clearly, an operation based primarily on reduction intrinsically exposes the surgeon to the possibility of excessive diminution of support structures and consequently undesirable side effects. The advent of the external approach in the 1970s marked a paradigm shift. In the early 1990s, the external approach witnessed further development with the introduction of "structural rhinoplasty," a deconstruction procedure followed by structural reconstruction. Opponents of the external approach felt that opening every nose can result in an overkill, specifically because the vast majority of patients presenting for cosmetic rhinoplasty neither desire nor require major reconstruction of the nose. In the last decade, the poorly named "closed" approach, once the pariah of rhinoplasty, has been rethought especially in the light of the undesirable long-term side effects, reappraised, and found a new lease of life as "endonasal rhinoplasty." The personal surgical evolution of the senior author (P. P.) has created the concept of "hybrid endonasal rhinoplasty" (HER), where the term "hybrid" implies the incorporation of anatomical concepts and sophisticated suturing-grafting techniques developed by "openers" into the theoretical and technical corpus of HER. The senior author (P. P.) pondered over heterogenous concepts such as filling-reshaping, derived from the so-called medical rhinoplasty, and embodied these concepts into a purely surgical endonasal perspective. Consequently, aesthetic rhinoplasty can be considered a "surface-contour" operation. Nasal analysis, preoperative work-up, surgical logic, and operative techniques have been rethought. The patient is only interested in nasal appearance, not in its anatomy, so deconstructing the nose to change the subtle and demanding interplay of light and shadow is in many cases an overkill. Our emphasis should be on those structures that can be tackled and result in the ultimate aim of altering the aesthetic aspects of surface anatomy. Surface HER can deliver on all these counts.

Modified Endonasal Tongue-in-Groove Technique.

Achieving stable and desirable changes in tip rotation (TR) and tip projection (TP) is among the primary goals of modern day rhinoplasty. The tongue-in-groove (TIG) technique is one technique in rhinoplasty used to improve TR and/or TP. Performing TIG endonasally using a permanent suture can be quite cumbersome as the suture needs to be buried under the skin. We describe a variation of TIG technique for endonasal rhinoplasty using a permanent suture buried in small columellar skin incisions. The technique details are described and the postoperative changes in TR and TP are analyzed for the degree of change and longevity. A retrospective review of the preoperative and postoperative photographs of 12 patients treated with the endonasal TIG technique were analyzed for changes in TR and TP. Out of 12 patients, there were seven females (58.3%) and five males (41.7%), with age ranging from 17 to 49 years. The follow-up ranged from 6 months to 53 months, with mean follow-up of 12.1 months. All patients were treated by the senior author in a major New York City hospital. Postoperative changes in TR and TP were compared by measuring the nasolabial angle as well as the Goode ratio using a photo editing software. Using a t-test and a p-value criteria of 0.05, the difference between the preoperative and postoperative TR (p = 0.0069) and TP (p = 0.026) was found to be statistically significant. None of the study patients developed any complications related to the use of a permanent suture material during the follow-up period. Our modified TIG technique is a quick, reliable, and safe option in the surgical armamentarium to achieve desired changes in TR and/or TP. 4.

Endonasal (Closed) Rhinoplasty Technique: Securing Spreader Grafts With Barbed Suture.

Spreader grafts are used for aesthetic and functional enhancement of the middle nasal vault in rhinoplasty. The spreader graft was originally described by Sheen as an endonasal (closed) rhinoplasty technique.1 More recently, most variations of the spreader graft have been described as anadjunct in theexternal rhinoplasty approach.2-4 The external approach allows improved visualization and access to the middle vault, which aids in accurately positioning and securing spreader grafts. In endonasal rhinoplasty, the correct placement and fixationof spreader grafts is typicallymorechallenging.4Knotless, “barbed” suture is a relativelynew technology that eliminates the need to tie knotswhile securing tissue. To our knowledge, we provide the first description of securing spreader grafts using barbed suture in endonasal rhinoplasty (Figure). The technique can be viewed in the Video.

Morphological and morphometric study of the cartilaginous framework of the dorsum and tip of the nose among Egyptian populations: a cadaveric study.

Success or failure of rhinoplasty depends mainly on the awareness of the surgeon with the construction of the nasal cartilaginous framework and the knowledge of the morphology and different dimensions of these cartilages. The current study aimed at evaluation of the morphology of the nasal cartilages and to address their different measurements as well as observation of anatomical variations of these cartilages and elucidation of their implications in rhinoplasty. Thirty adult human cadaveric noses, males and females aged 20-70 years were used in the current study. The specimens were dissected; cartilages were exposed and examined morphologically for shape, parts and attachments. Different nasal cartilage measurements were done. The examination of nasal cartilage revealed that the mean length of upper lateral cartilage was variable. The mean width and thickness were 12.8 ± 1.29 mm and 1.34 ± 0.14 mm, respectively. The mean length, width and thickness of alar cartilage were assessed. Angle of divergence was observed to be 23-44°. Statistically, there were no significant differences between genders. Data obtained from this study confirmed the anatomical varia-tions of the nasal cartilages among the Egyptians and confirmed the differences with several ethnic groups. This has important surgical implications giving the attention required during different techniques in rhinoplasty in order to maintain dorsal aesthetic lines of the nose and proper respiratory function.

The Tongue-in-Groove Technique in Primary and Revision Rhinoplasty.

The tongue-in-groove (TIG) is a conservative but powerful surgical suture technique to control tip rotation and projection, to set an appropriate alar-columellar relationship, to straighten a caudal septal deviation, and to stabilize the nasal base. TIG is suitable in primary and most revision cases and is easily combined with other surgical techniques. Seventeen years after its popularization, the TIG technique is embedded in modern-day rhinoplasty literature and teaching material. This article describes indications and considerations during external primary and revision rhinoplasty, based on clinical experience and the available literature.

An Overview of Asian Rhinoplasty

East Asian rhinoplasty is an expanding topic in the field of rhinoplasty. Although the main principles of various rhinoplasty techniques apply equally to the East Asian nose, East Asian rhinoplasty is unique owing to its different anatomy and ethnicity. In recent years, there have been some noteworthy developments in East Asian rhinoplasty. Traditional techniques using alloplastic implants with endonasal approach are changing due to the advent of new beauty concept, introduction of new techniques, and development of newly improved materials expended polytetrafluoroethylene as an alloplastic material has gained popularity in Asian augmentation rhinoplasty. Soft expended polytetrafluoroethylene sheets as augmentation material provide promise in the future. In this review, we will highlight some of the recent advances of Asian rhinoplasty with emphasis on dorsal augmentation, advances in implant material, and tip surgery using autologous cartilage.

Uses of Various Grafting Techniques in External Approach Rhinoplasty: An Overview.

The surgeons performing rhinoplasty found Graft selection the greatest challenge. To avoid an immune response the preferred choice thus far for nasal reconstruction would be autograft compared to allograft due to its lower rate of rejection. We have evaluated 30 patients who underwent open rhinoplasty and We used conchal and septal cartilaginous grafts in various forms by the open approach to correct various nasal deformities compared our experience regarding the operative technique, graft availability, indications, and limitations. No bony graft material or synthetic materials were used. Preoperative extensive evaluation of the patient was done in order to determine the type of deformity and the type of graft to be used in order to correct the deformity. Preoperative and postoperative photographs were taken in four basic views: frontal, lateral, lateral-oblique and basal in order to assess the results of the surgery. The study was done on 30 patients (20 male and 10 females) using the external rhinoplasty approach using the septal and conchal cartilages in different forms. Autologous septal cartilage was used in most of the patients (25 out of 30) and conchal cartilage was used in 5 patients. Multiple grafting techniques were used in some patients. Three patients had traumatic etiology. Columellar strut graft along with TIG technique was used in 16 patients, spreader graft was used in 8 patients, and septal extension graft was used in 5 patient and shield graft in 1 patient. Septorhinoplasty continues to evolve through various new techniques and modifications with the main goal to improve functional nasal airway and to restore cosmetic harmony to the face. Optimum result is very much dependent on the surgeon's attention to functional, aesthetic, and reconstructive principles and graft selection.

Comparison of Permanent Versus Absorbable Suture in the Tongue-in-Groove Technique in Endonasal Rhinoplasty

The tongue-in-groove technique in endonasal rhinoplasty is a commonly used method for making changes in tip rotation and projection. We examine the outcomes of absorbable and permanent suture tongue-in-groove technique in relation to maintaining postoperative tip rotation and projection. A retrospective review of the preoperative and postoperative photographs of 18 patients treated with endonasal tongue-in-groove technique were analyzed. Twelve patients were treated with nylon suture and 6 with polydioxanone suture (PDS). There were 9 females (50%) and 9 males (50%), with the age ranging from 17 to 49 years. The mean follow-up time was 12.1 months. All patients were treated by the senior author in a New York City hospital. All patients were treated with the tongue-in-groove technique in endonasal rhinoplasty; 5.0 clear Nylon suture was used on 12 patients and 5.0 clear PDS on 6 patients. Using an unpaired t test and an alpha value of 0.05, the difference between the preoperative and postoperative tip rotation and projection was statistically significant for nylon ( P = .0069, P = .026) but not for PDS ( P = .27, P = .15). Using permanent suture in tongue-in-groove technique during endonasal rhinoplasty seems to be a more reliable method for maintaining postoperative changes in tip rotation and projection.

Management of Saddle Nose Deformity Using Dermal Fat and Costal Cartilage “Sandwich” Graft: A Problem-Oriented Approach and Anthropometric Evaluation

In the surgical treatment of saddle nose deformity (SND), costal cartilage is often used. However, it can result in some potential complications such as resorption, bending, displacement, and its appearance under the skin (silhouette deformity). We prepared a composite "sandwich" graft by camouflaging the costal cartilage underneath the dermal fat graft as a novel method and applied it on SNDs using the closed rhinoplasty technique to prevent or minimize these risks. The method was used for 21 patients (12 males and 9 females). Six anthropometric measurements, including the nasal dorsum projection, nasal supratip projection, nasal tip projection, nose length, labiocolumellar angle, and nasofrontal angle, were taken using the ImageJ program (National Institutes of Health, Bethesda, MD) on preoperative and postoperative lateral photographs. The data were compared statistically. The mean follow-up time was 29.95months. No donor site complications developed. The sandwich grafts transferred to the nose were well tolerated in all patients. A partial graft failure and a mild bending, which were treated conservatively without supplemental surgery, developed in 1 patient each. No resorption, migration, bending, or appearance under the skin of the sandwich grafts were seen in the remaining patients. A statistically significant difference was found in all anthropometric measurements from the preoperative and postoperative groups except for2. The severity of the deformity should be exactly determined before surgery, and cartilage grafts should be used accordingly for successful repair of SND. The sandwich technique, as a practical, effective, and long-lasting treatment method, could minimize the potential complications and risks of revision.

Reconstructive Rhinoplasty Using Multiplanar Carved Costal Cartilage.

Reconstructive rhinoplasty often requires the use of cartilage grafts. Full-thickness autologous costal cartilage grafts provide a large amount of cartilage in a single uncarved block and are often used for major reconstructions. Warping is frequently described as a complication of rib cartilage use in rhinoplasty. To describe an approach to cartilage carving whereby a single block of cartilage is carved in a multiplanar manner to mimic or redefine the anatomic relationships and resist warping. A retrospective review of reconstructive rhinoplasty cases using multiplanar costal cartilage grafting technique was performed. A consecutive sample of 11 patients with complex nasal deformity underwent reconstruction with an autologous costal cartilage block carved in 3 dimensions to address complex deformities at the University of New Mexico Hospital between January 2010 and December 2014. The follow-up period ranged from 3 to 36 months. Autologous rib cartilage harvest was performed to obtain a full-thickness segment of rib cartilage. The deficient or malformed nasal cartilage is defined and soft tissue prepared using an open rhinoplasty approach. Rib cartilage graft curvature is removed to create a uniform, symmetric, solid block of cartilage. A cartilage graft is carved in a multiplanar fashion to simulate normal nasal anatomy. Postoperative evaluation of nasal airway function, cartilage graft warping, and aesthetic outcomes were reported in the follow-up period. Nasal Obstructive Symptom Evaluation (NOSE) scores are documented in the majority of cases and were obtained at least 3 months postoperatively. Overall, 11 patients with complex nasal deformity underwent reconstruction with an autologous costal cartilage block carved in 3 dimensions. The most common use was for reconstruction of the septum with the upper lateral cartilage. There were no major complications. No patients experienced graft warping in the follow-up period. Several patients required minor revision procedures. All patients reported improved nasal airway and improved aesthetic appearance of the nose. Multiplanar costal cartilage grafting is a useful surgical technique for complex reconstructive rhinoplasty that yields optimal and predictable results. 4.

Outcomes of Primary Unilateral Cheiloplasty in Same-Day Surgical Settings.

BackgroundFinancial, clinical, and psychological considerations have made same-day surgery an attractive option for a variety of procedures. This article aimed to analyse the postoperative results of same-day primary unilateral cleft nasolabial repair.MethodsThis study was performed from 2011 to 2014. Unilateral cleft lip patients fulfilling the inclusion criteria were preoperatively classified as mild, moderate, and severe. All patients underwent same-day surgery and were discharged after satisfying the appropriate clinical criteria, receiving thorough counselling, and the establishment of a means of communication by phone. Postoperative outcomes were assessed and stratified according to preoperative severity and the type of repair.ResultsA total of 423 primary unilateral cleft lip patients were included. Fisher's anatomical subunit approximation technique was the most common procedure, followed by Noordhoff's technique. The postoperative outcome was good in 89.8% of cases, fair in 9.9% of cases, and poor in 0.2% of cases. The complication rate was 1.18% (n=5), and no instances of mortality were observed. The average hospital stay was 7.5 hours, leading to a cost reduction of 19% in comparison with patients who stayed overnight for observation.ConclusionsMild unilateral cleft lip was the most common deformity for which Fisher's anatomical subunit approximation technique was performed in most of the cases, with satisfactory postoperative outcomes. Refinements in the cleft rhinoplasty techniques over the course of the study improved the results regarding cleft nasal symmetry. Single-day primary unilateral cleft cheiloplasty was found to be a cost-effective procedure that did not pose an additional risk of complications.

Technique in Cleft Rhinoplasty: The Foundation Graft.

Secondary cleft rhinoplasty represents a particular surgical challenge. The authors have identified the deficit in skeletal projection of the cleft-sided piriform rim as an important contributor to the pathology. A graft is described to augment the piriform crest on the cleft side. This foundation graft is suture fixated to the piriform crest after complete release of all soft tissue attachments to the alar base. The foundation graft is articulated with a long alar strut graft, which allows for powerful projection of the cleft-sided nasal tip. An advancement flap of vestibular skin is described to correct the vestibular stenosis. A transplant of diced cartilage in fascia is added to augment maxillary soft tissue volume. Subjective and objective measures of form and function are presented in a retrospective series of five cases, illustrating the efficacy of the techniques described.

A Combined Approach To Crooked Nose Deformity.

Crooked nose deformity is a complex anatomical deformity; therefore, repair remains a challenge. Here, we introduce a new technique for crooked nose deformity repair. Twenty-two patients underwent intraoperative evaluations and measurements, followed by surgery using the open rhinoplasty technique. Our method involves three major steps. First is the creation of an asymmetric medial oblique osteotomy using piezoelectric ultrasonic surgery and double lateral osteotomies, wherein the asymmetric bony ascending part of the maxillary bone at the base of the nasal vault is fractured, pushed in, and delivered to the face. Second is septoplasty with L-strut preservation. The L-strut is removed as a 1-cm block caudally from the septal stump of the keystone area. A (or double) fabricated batten cartilage graft is placed on the concave side of the deviation and sutured to cover the septal stump. The L-strut is then replaced and sutured on the batten graft, redirecting the septum toward the midline. Third is an overlapping cruroplasty on the side of the long asymmetrical lower lateral cartilage to equalize both wings and correct tip deviation. Our new technique was effective for the treatment of crooked nose deformity. Our technique of K-stone batten plasty with delivery to the face and overlapping cruroplasty may be an effective surgical method for crooked nose deformity. 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 .

The Conchal Cartilage Butterfly Graft.

Nasal obstruction due to weakening of the nasal sidewall is a very common patient complaint. The conchal cartilage butterfly graft is a proven technique for the correction of nasal valve collapse. It allows for excellent functional results, and with experience and attention to technical detail, it may also provide excellent cosmetic results. While this procedure is most useful for restoring form and function in cases of secondary rhinoplasty following the reduction of nasal support structures, we have found it to be a very powerful and satisfying technique in primary rhinoplasty as well. This article aims to describe the butterfly graft, discuss its history, and detail the technical considerations which we have found useful.

Long-Term Results and Refinement of the Turkish Delight Technique for Primary and Secondary Rhinoplasty

All grafts present the potential problem of late visibility, distortion, and (occasionally) absorption. To overcome these problems and obtain a smoother surface, in 1989, the author initiated the use of finely diced cartilage wrapped in Surgicel. It is well known that the resolution of edema at the end of 1 year postoperatively is approximately 90 to 95 percent. Complete resolution continues until the end of 4 years postoperatively. However, it is important to understand what occurs beyond 4 years, and how the nose changes as the face ages. The author presents his experience of the past 25 years on 9398 primary and secondary rhinoplasty patients treated using his personal approach, the Turkish delight. Patients with a postoperative range from 4 to 25 years were selected. The Turkish delight type of cartilage graft (diced cartilage wrapped in Surgicel) has been free of late show complications often experienced with other types of tip grafts. Long-term results from 4 to 25 years are very satisfactory, with an acceptably low complication rate. This technique is safe, reliable, effective, simple, and easily applicable by plastic surgeons at all levels of experience. Early and long-term results from 1 to 25 years are very satisfactory. The overall complication rate is very low compared with other techniques. In addition, there is no late show as is sometimes seen with other types of cartilage grafts such as crushed, oval, or rectangular grafts. Therapeutic, IV.

A Practical Approach for Learning Rhinoplasty Surgery

ABSTRACT Rhinoplasty surgery is a procedure well suited for otolaryngology residents to incorporate in their training and subsequent practices of medicine. We detail a practical approach for learning rhinoplasty which may commence during residency. The resident learns to conduct a proper consultation, preoperative evaluation, surgical procedure, and follow-up care for the prospective rhinoplasty patient. The history of rhinoplasty, and modern rhinoplasty techniques is discussed, and suggestions are made for residents to successfully incorporate learning rhinoplasty surgery during their otolaryngology training. How to cite this article Kaplowitz LJ, Joseph EM. A Practical Approach for Learning Rhinoplasty Surgery. Int J Head Neck Surg 2016;7(1):33-46.