Tip Grafts Research Articles

Lateral Crural Tensioning for Refinement of the Nasal Tip and Increasing Alar Stability: A Case Series.

AbstractThe objective of this study was to discuss the technical details and our experiences with lateral crural tensioning (LCT) in both functional and aesthetic rhinoplasties. A retrospective medical review was completed for all patients who underwent rhinoplasty with LCT from the years 2011 to 2014. The indications for LCT included correction of lateral crural convexity, boxy tip geometry, and dynamic collapse of the external nasal valve. The details of the rhinoplasty procedure and complications were evaluated. A total of 114 LCT rhinoplasty cases were included in this series. The most common adjunctive maneuvers included placement of spreader grafts (92% of cases) and alar rim grafts (78% of cases). Conventional classic cephalic trim was not performed in any subjects and conservative paradomal cephalic trim was performed in 48% of cases. As experience with the technique progressed, the use of onlay tip grafts decreased and the use of articulated rim grafts increased. Indications for revision were dissatisfaction with cosmetic outcome (4.4% of cases) and nasal obstruction (0.9% of cases). LCT combines traditional lateral crural steal with the use of a caudal septal extension graft to refine the broad tip and increase stability of the alar lobule. This maneuver is essentially cartilage sparing and does not rely on extensive grafting maneuvers that can reduce airway area.

Commentary on 3D Photogrammetric Analysis of the Nasal Tip Projection and Derotation Based on the Nasal Tip Quadripod Concept.

Asian noses are mainly characterized by a low nasal dorsum, a short nose and an underprojected nasal tip due to underdeveloped (short and weak) alar cartilages. The goals of the surgery are to increase the tip projection, elongate the nose and augment the dorsum. In Asian noses the structural approach helps strengthen the weak cartilages and add definition to the nasal tip. There are various methods to increase tip projection and definition. Columellar strut, caudal septal extension graft, tip grafts and lateral crural grafts in order to elongate the upper legs of the nasal tip tripod can be used. The method described in this article seems a useful solution in Asian rhinoplasty patients who do not want to use rib cartilage. The "Skiff Graft" functions similar to caudal septal extension graft with its elongation and raise effect at the caudal septum. However in cases which need significant increase in tip projection and nose elongation, this method may be insufficient. In such cases, stronger structural grafts prepared from rib cartilage will give a better tip definition and more predictable outcome.

Modified lateral crural spanning suture of the nasal tip: Suspension element

IntroductionSeveral techniques have been described to improve nasal tip definition, such as cartilage resection, tip grafts, and suture placement. Lateral alar convexities are a common deformity that requires attention during rhinoplasty. The lateral crural spanning suture provides a predictable, accurate method of correcting excess lateral crural convexity without the need for procedures that would compromise the integrity of the cartilage. ObjectivesAiming to achieve the maximum support of the nasal tip and to maintain the position of the tip in a fashion that prevents postoperative droopiness, we have modified the classic lateral crural spanning suture. MethodsA prospective study of 113 patients was conducted over patients presented to our hospital aiming at improving nasal tip definition through modified lateral crural spanning suture. ResultsIn this study, added improved of the nasal tip width and rotation was achieved in all the patients admitted for rhinoplasty.

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.

Reconstruction of the maxilla following hemimaxillectomy defects with scapular tip grafts and dental implants

Treatment of post-resective defects of the maxilla can be challenging and usually requires dental obturation or microvascular reconstruction. As compared to soft-tissue microvascular grafts, bone reconstruction can additionally allow for facial support and retention of dental implants. The aim of this study was to evaluate scapular tip grafts with respect to their applicability for maxillary reconstruction and their potential to retain dental implants for later dental rehabilitation. In this retrospective study, 14 patients with hemimaxillectomy defects were reconstructed with free scapular tip grafts, oriented horizontally, to rebuild the palate and alveolar ridge. After bone healing, three-dimensional virtual implant planning was performed, and a radiographic guide was fabricated to enable implant placement in the optimal anatomic and prosthetic position. All patients' mastication and speech were evaluated, along with the extent of defect closure, suitability of the graft sites for implant placement, and soft-tissue stability. Pre- and postsurgical radiographs were also evaluated. A good postoperative outcome was achieved in all patients, with complete closure of maxillary defects that were class II, according to the system of Brown and Shaw. Additional bone augmentation was necessary in two patients in order to increase vertical bone height. Patients were subsequently treated with 50 dental implants to retain dental prostheses. In all cases, additional soft-tissue surgery was necessary to achieve a long-term stable periimplant situation. No implants were lost during the mean observation period of 34 months. Due to its specific form, the scapular tip graft is well suited to reconstruct the palate and maxillary alveolar ridge and to enable subsequent implant-retained rehabilitation. Due to the limited bone volume, an accurate three-dimensional graft orientation is essential. Furthermore, most cases require additional soft-tissue surgery to achieve a long-term stable periimplant situation.

Application of ear cartilage in reconstruction of domal graft in nasal tip rhinoplasty

Objective To investigate the application of auricular cartilage in nasal plastic surgery and its clinical effects of the different tip graft and reconstructed domal graft (RDG). Methods From October 2009 to May 2015, the surgical procedure was performed on 286 patients, through the application of cymba and conchae cartilages into various tip graft and RDG in nasal tip plasty. Results A total of 286 patients were followed up post-operatively for 3 months to 5 years, 245 patients (85.7% achieved expected stability tip, the tip down to 1-2 mm after one year. Tip skin thinning was observed in 10 patients after one year, nasal tip down occurred in 89 patients; the columella skew and asymmetric nostrils occurred in 31 patients. Conclusions The ear cartilage can be made into various tip graft for rhinoplasty, with satisfactory clinical outcomes. Key words: Auricular cartilage; Rhinoplasty; Graft

The Pi Graft for Correction of Severe Saddle Nose Deformity.

Saddle nose deformity is challenging because there is both aesthetic and functional compromise, and high rates of recurrence have been reported. Autologous costal cartilage is the widely preferred medium for reconstruction, but there may be room for improvement in the configuration of the cartilage struts. The pi graft is stabilized at two points, proximally and distally, distinguishing it from the traditional L-strut. Indications include severe (Types III and IV) saddle nose deformity with collapse of the mid-vault, and recurrence after prior reconstruction. Costal cartilage is harvested and three struts are crafted to make the foundation layer: a dorsal strut, caudal strut, and mid-vault strut. An aesthetic layer is composed of a carefully crafted dorsal graft and tip graft. Three men and 11 women were treated from 2013 to 2015 using this method for severe saddle nose deformity. Aesthetic and functional outcomes were evaluated. Patients were followed up for 12 months (range, 8-14 months). There was no recurrence of deformity or warping of the aesthetic or foundation layers. All patients were guided to anticipate refinement of the tip at 3 months to ease the burden on the skin envelope in stage I, but only five patients (35.7%) opted for it, as the remaining patients were satisfied with their appearance. The pi graft is a composite reconstructive method that is designed to minimize warping and recurrence of the saddle nose deformity. This method was successful in this series, although objective comparisons with traditional methods were not made.

Columellar Incision Scars in Asian Patients Undergoing Open Rhinoplasty.

An open approach has been adopted for rhinoplasty because of its wide and undistorted exposure. The formation of a columellar incision scar is the main drawback of this approach. To evaluate the incidence and evolution of and risk factors for columellar incision scars in an Asian population. A retrospective case series of 529 patients who underwent open rhinoplasty was performed in a tertiary care referral center in South Korea from January 1, 2011, to May 31, 2014. Problematic transcolumellar incision scars were categorized into wide and depressed, notching, and hyperpigmented wound types. Follow-up was complete on January 28, 2015, and data were assessed from July 1, 2014, to May 29, 2015. The incidence of each problematic scar and the time course of erythema evolution were evaluated. Factors affecting the formation of a problematic scar were also evaluated. Of 529 patients (176 female and 353 male patients; mean age, 31 [range, 5-70] years), 234 patients with at least 6 months of follow-up underwent evaluation for a problematic scar. Fourteen of the 234 patients (6.0%) had problematic incision scarring (wide and depressed wound, 4 [1.7%]; notching wound, 3 [1.3%]; hyperpigmentation, 4 [1.7%]; marginal incision hypertrophic scar, 2 [0.8%]; and columellar skin necrosis, 1 [0.4%]). Of the 243 patients with regular follow-up who underwent evaluation for erythema evolution, erythematous wounds were found in almost all in the immediate postoperative period and had normalized by a mean (SD) of 66.7 (37.4) postoperative days. Use of costal cartilage as tip graft material was associated with a problematic incision scar (2 of 25 patients [8.0%] vs 6 of 180 patients with other graft material [3.3%]; P = .02). In this cohort of Asian patients, the incisions used for an open rhinoplasty approach had some problems. However, the low incidence of problematic scars indicates that open rhinoplasty should not be discouraged because of the incision scar. 4.

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 Novel Method for Smooth Contouring of Nasal Tip: Camouflaging Alar Tip Graft.

The aim of this article is to define a tip graft that provides camouflage for a smoothly contoured, natural-looking tip and that prevents long-term graft visibility. When traditional grafts are used to substantially increase tip projection, there is a possibility for thinning of the skin and subsequent graft visibility. To avoid such unwanted results, the authors have developed a novel graft: the camouflaging alar tip (CAT) graft. In this study, the authors provide a retrospective analysis of the long-term follow-up of 742 patients from 2003 to 2013 in whom a CAT graft was placed. This article is a synopsis of the authors' 10 years experience in nasal tip surgery.

Principles of Structural Rhinoplasty in South East Asian Noses

Principles of Structural Rhinoplasty in South East Asian Noses

Use of aesthetic rhinoplasty procedures in reconstructive nasal surgery

Resection of cancer often involves the excision of underlying hard tissue, and some procedures in aesthetic rhinoplasty can be used in reconstructive nasal surgery to increase the margin of safety while still achieving an acceptable aesthetic and functional outcome. We have used techniques from aesthetic rhinoplasty to shape the nasal framework. Osteotomy and formation of the tip were used in 17 patients with defects (ranging from 1 to 3.5cm in size) from the nasal root to the tip of the nose. After the underlying bony or cartilaginous framework, or both, had been removed, the resulting open roof deformity had to be corrected by osteotomy of the bony nasal wall and the tip shaped by excision and suturing, including insertion of the tip graft and columellar strut graft. After this, and narrowing of the nose, the defect was smaller and could be closed with local tissue without tension. There were no deformities in the contour, and patency of the airway was maintained. Patients were satisfied with both the aesthetic and functional results. Although the margin of safety was increased, shaping the nasal framework reduced the size of the defect, which allowed tension-free closure with a local flap. The operation requires a thorough knowledge of procedures used in aesthetic rhinoplasty.

Aggravation of Relapsing Polychondritis due to the Infection and Its Manifestation on a Nasal Tip Graft

Relapsing polychondritis (RP) is an uncommon systemic disease that is characterized by episodic and progressive inflammation of the cartilaginous structures, which can be very debilitating and in some instances life-threatening. The pathogenic pathways of RP are largely unknown. However, several hypothesis have been suggested. We had an interesting case of aggravation of RP due to the infection. Graft cartilage on the nasal tip was affected by RP also. This case can give a clue of revealing the pathogenesis of RP. We introduce a case with a review of the literature.

An alternative technique to define and visualize columellar and nasal tip vectors. Improvement of mestizo nose

BackgroundWith some frequency, in mestizo rhinoplasty, we focus much of our attention on the nasal tip. This work also highlights the importance of obtaining a proper balance of the columella, achieving a pleasing visual effect of the vector lines that make up the nasal profile (columella and nasal tip vectors). MethodsWe performed a complete medical history in all patients and developed a surgical plan after nasal anatomy analysis. Pre- and postoperative photographs were obtained for medium and long term control. ResultsWe treated 112 patients with this surgical technique, 77 with an open approach and 35 with a closed approach. The results were documented in the short and long term with a range of 6months to 5years. ConclusionsWe feel that the use of an angulated extended columellar graft is highly polyfunctional, providing length, definition and support to nasal tip grafts. Because of the graft design, it is possible to predetermine the new columella length/tip, thus visualizing the columella and nasal tip vectors of the nasal profile. The angulated extension prevents cephalic–lateral–caudal displacements of the tip graft, and to some degree it is possible to increase or decrease nasal length depending on the angularity of the extension.

Current Clinical Practices of the Rhinoplasty Society Members

As rhinoplasty remains among the most challenging and controversial operations in plastic surgery, we sought to elucidate present-day practice characteristics. Members of The Rhinoplasty Society were polled in preparation for the national meeting held in Boston, Mass, on May 2011. The goal was to provide information regarding surgical approaches used as well as technique and practice patterns used. Two electronic surveys were distributed to members of The Rhinoplasty Society in preparation for the annual meeting. All 76 members received the surveys as well as instructions for completion. The initial survey included 10 questions discussing the preferred approach for rhinoplasty and practice details. The second survey dealt with specific techniques used during rhinoplasty. Data were collected and reviewed. The primary survey yielded a 61.8% response rate, whereas the secondary survey 48.7%. Of all surgeons, 72% reported doing the open approach for primary rhinoplasty more than 50% of the time, whereas the remaining 28% use the closed approach. For secondary rhinoplasty, 76% reported using the open approach in more than half of cases for which they were not the primary surgeons. In contrast, 53% used the closed approach in more than half the cases of secondary surgery if they were the initial surgeons. Revision rates for primary and secondary rhinoplasties were 9.1% and 7.8%, respectively. The difference was not statistically significant. On average, members performed 101 nasal surgeries per year. Previous patient recommendation was the most common reason for referral. Of the members, 54% reported using spreader grafts in more than half of the cases of aesthetic rhinoplasty and 75.7% when pertaining to functional rhinoplasty. Finally, 37.8% of responding members reported using tip grafts more than half the time when performing aesthetic rhinoplasty. Of the responding members of The Rhinoplasty Society, the open approach is the preferred choice for both primary and other surgeons' revision rhinoplasties. Spreader grafts are commonplace in both functional and aesthetic rhinoplasties.

Lengthening the Short Nose in Asians

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

A Modified Septal Extension Graft for the Asian Nasal Tip

Septal extension graft is an effective procedure in tip plasty because it can provide stable structural support for the nasal tip. However, in Asian patients septal cartilage is much weaker, thinner, and smaller than that of white people, causing the existing caudal septal cartilage and the septal extension graft to deviate to the opposite side of graft placement. To introduce an effective and reliable modified septal extension graft in tip plasty. Observational study of a total of 143 patients (84 undergoing primary rhinoplasty and 59 undergoing secondary rhinoplasty). A modified septal extension graft technique in combination with other procedures, including tip graft and implant augmentation. Subjective evaluation based on photographic analysis. This procedure was applied in 143 Asian patients, with substantial improvement seen in the nasal tip of all patients except for 3 (1 for the overprojected nasal tip and 2 for bending of existing caudal septum). Other complications included infection in 1 patient and implant deviation in 1 patient; the implant and grafts were removed 10 days after surgery in the patient with infection. The other patient underwent revision 3 months after surgery for the deviated implant. This technique is an effective method to provide long-term, stable nasal tip support. It helps to set the existing caudal septum and the septal extension grafts exactly at the anterior midline and decrease the deviation of the nasal tip. 4.

CONCEPTS AND TECHNIQUES OF NASAL TIP SURGERY

Background: Rhinoplasty is one of the most challenging procedures in plastic surgery. It is technically demanding, and tip surgery is an art form. It requires an in-depth knowledge of the complex three-dimensional anatomy of the nose, a complete understanding of its physiology, familiarity with the described techniques of nasal tip surgery, and a well-developed sense of aesthetics. Aim of the work: This article will describe different techniques used to create a refined, aesthetically pleasing nasal tip. Patients and methods: The patients in this study were selected from of Dr John Hodges, M.D’ Office, Veterans Hospital, and Methodist hospital, USA, and Zagazig University hospital, Egypt. The study was carried out on 50 patients with different nasal tip deformities, who underwent rhinoplasty, they were 15 males and 35 females, their age ranging from 20 to 60 years old. Two approaches had been selected; an open approach had been done for 30% of our patients, and a closed approach had been done for 70% of our patients with different nasal tip techniques. Results: The results of this study for nasal tip refinement techniques demonstrated a decrease in reductive and irreversible techniques as cartilage transection, domal truncation , morselization, and scoring that had been done in 8% of our patients for each, with a concurrent increase in stabilizing, strengthening, and reorientation techniques as sutures and grafts techniques that had been done in 60% of our patients for each; so cartilage-dividing techniques and the vertical dome division are rarely necessary to reduce projection, broadness, and/or rotation of nasal tips, they have been used if suture and graft techniques do not achieve the adequate nasal tip definition. Conclusion: The simplest approach for refinement of nasal tip deformity that allows the planned surgical techniques to be performed without difficulty and cause the least disturbance to the tip’s support, should be selected. Thus, we recommend the reversible, non destructive techniques as sutures and tip grafts for remodeling the tip deformities, with closed approach once indicated. Keywords: Rhinoplasty, nasal tip refinement

Rhinoplasty

Congenital deficiencies of the alar cartilages are rare and often visible at birth but can occasionally present later. The authors review the anatomical development and discuss the incidence and treatment of congenital defects within the alar cartilages seen in rhinoplasty cases. The charts of 869 consecutive patients who underwent open rhinoplasty were retrospectively reviewed, and 8 cases of congenital defects of the alar cartilage within the middle crura were identified. Intraoperative photographs were taken of the alar deformities, and each patient underwent surgical correction. To simplify analysis, a classification of the defects was developed. A division was a cleft in the continuity of the alar cartilage with the 2 ends separate. A gap was a true absence of cartilage ranging from 1 to 4 mm, which can be accurately assessed in unilateral cases. A segmental loss was a defect greater than 4 mm. The 8 cases of deformity could be classified as 4 divisions, 3 gaps, and 1 segmental loss. None of the patients had a history of prior nasal trauma or nasal surgery. Six patients were women and 2 patients were men. In all cases, adequate projection and stability were achieved with a columellar strut. Asymmetry was minimized through concealer or tip grafts. There were no complications. Surgeons performing rhinoplasty surgery will encounter and should be prepared to deal with unexpected congenital defects of the alar cartilage. These defects within the middle crura will require stabilization with a columellar strut and, often, coverage with a concealer tip graft. We speculate that the cause of these defects is a disruption of the hedgehog signals that may arrest the condensation or block the differentiation of the underlying neural crest cells.

Comparison of different autografts for aural cartilage in aesthetic rhinoplasty: is the tragal cartilage graft a viable alternative?

Auricular cartilage is an important source of grafts for various reconstructive procedures such as aesthetic rhinoplasty. The purpose of this investigation was to compare tragal cartilage with auricular cartilage harvested from the concha and scapha, and describe its clinical viability, indications, and morbidity in rhinoplasty. A total of 150 augmentation rhinoplasties with a total of 170 grafts were included. The donor sites were tragus (n=136), concha (n=26), and scapha (n=8). The time needed to harvest the grafts, the donor site morbidity, and the indications for operation were recorded. The anthropometric changes to 4 auricular variables after the cartilage had been harvested were analysed and compared with those on the opposite side in 48 patients using Student's paired t-test. Intraobserver reliability was assessed using Pearson's intraclass correlation. The mean (SD) harvesting time was 27 (8) min for the concha, 4.5 (1.4) min for the tragus, and 5.7 (1.6) min for the scapha. The largest graft was taken from the concha (28×19mm), followed by the tragus (20×12mm), and the scapha (18×6mm). The grafts were placed at the following sites: tip grafts (n=123), columella struts (n=80), shield (n=20), rim (n=17), and dorsal onlay (n=15). Harvesting tragal cartilage is safe, simple, fast, and has a low morbidity, but it can affect the patient's ability to wear earphones. Tragal cartilage is a good alternative for nasal reconstruction if a graft of no longer than 20mm is required.