Tip Plasty Research Articles

Clinical application of autologous auricular cartilage in nasal tip plasty

Objective To observe and discuss the application and clinical effect of different forms of ear cartilage in nasal tip plasty. Methods Auricular cartilage was used to prune it as halberd at first, and then the extended transplantation and the cartilage fornix reconstruction were carried out by using single or combined septum cartilage. Meanwhile, nasal tip plasty was performed by using cap shape or shield shape cartilage grafting. Results 136 patients were followed up for 6 to 24 months after operation. 119 cases were satisfied, accounting for 87.5%, of which 11 cases (ear cartilage weakness) were not improved obviously, accounting for 8%. However, there were only 6 cases with the unsatisfactory feedback as the nasal tip that was decreased by 1~2 mm one year after the operation, accounting for 4.41%. Conclusions The auricular cartilage is pruned as halberd singly or combined with septal cartilage as an extended graft, reconstructing the cartilage fornix in the meantime, which is the way better than the traditional way of making nasal tip plasty to obtain the ideal nasal tip protrusion. Key words: Rhinoplasty; Ear cartilage; Autografts; Halberd shape; Cartilage fornix reconstruction

An Innovative and Easy Dome Holding Technique for Transdomal Suture in Rhinoplasty.

Suture tip plasty is one the most used methods in nasal tip surgery. Transdomal suture (TDS) used for this purpose is utilized for providing the dome symmetry, thinning the nasal tip, and enhancing the nasal tip projection and rotation. However, there are not sufficient visual data on what the dome position should be during TDS. In this study, it was aimed to be directive in tip plasty and to define the convenient dome holding technique during TDS. Patients, 510 male and 621 female at the age of 18 to 50 years, who underwent the open technique septorhinoplasty between the years of 2003 to 2015 were included in the authors' study. The length of the patient follow-up varies between 1 and 10 years. Patients, on which the lateral crural strut graft was used and which underwent dome division/vertical dome division in tip surgery, and patients who were diagnosed with the alar cartilage asymmetry and underwent dome excision for any pathological reason to demonstrate the effectiveness of the TDS holding technique. During the TDS, the dome area was administered with 5/0 polydioxanone by being held at an angle close to the cranial in the posterior and the caudal in the anterior with a dentated forceps. In this study according the authors' pre and postoperative conclusions, the authors consider that this is a sufficient visual data on what the dome position should be during TDS by presenting video.

A Novel Technique of Asian Tip Plasty: Rein-Shaped Columellar Strut Graft

The columellar strut graft is one of the most commonly used invisible grafts in tip plasty techniques for nasal tip projection. However, the columellar strut graft induces cephalic rotation of the dome with nasal tip projection. This is an effective change in Western people with a long nose; however, this change should be avoided in Asians who have a relatively short nose and visible nostrils. We designed a more convenient and effective technique using a rein-shaped columellar strut graft that can prevent cephalic rotation of the dome. A total of 32 patients underwent surgery with a rein-shaped columellar strut graft with a septal cartilage. The projection and location of the nasal tip, nasal length, and nasolabial angle were measured after taking a photograph of the lateral view, and the preoperative and postoperative results were compared. There were statistically significant differences between the preoperative and postoperative values of the nasal tip projection ratio and nasal tip location ratio. There were no revision surgeries and no direct complications associated with the use of the columellar strut graft. We performed tip plasty with a modified columellar strut graft-the rein-shaped columellar strut graft. In most cases of using this method, the tip projection was increased and the cephalic rotation of the tip was prevented. This surgical procedure can also be used for lengthening (rotating caudally) of the nose in some cases, as well as for the purpose of preventing the cephalic rotation of the tip. 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 .

Lateral crural overlay of the lower lateral cartilages, a technique to enhance nasal tip rotation, and reduce projection in the droopy nasal tip

Background and objective: Tip plasty is one of the most common feats encountered by the Aesthetic Rhinoplasty Surgeon. Tip rotation, with or without tip deprojection, is one of the challenging problems that face the surgeon, with many overwhelming techniques to correct rotation and projection of the nasal tip, including, but not limited to overlapping of the lateral crural cartilages. This study aimed to assess the efficacy and reliability of the technique of the lateral crural overlay of the lower lateral cartilages in enhancing nasal tip rotation and decreasing nasal tip projection. Methods: This prospective study included 64 patients, who underwent primary, and secondary, open Rhinoplasty, with nasal droopy tip and nasal tip true overprojection problems. They have been treated in Sulaimaniyah Hospital for Burn and Plastic Surgery, and from Private Hospitals in Sulaimaniyah city. The age range was 18-34 years. Forty nine patients were female, the rest of the patients were male. They have been treated, primarily, for the tip drooping and to a lesser extent for nasal tip overprojection, by the senior author, with Lateral Crural Cartilages Overlay. The study conducted from April 2012 to January 2016. The patients, postoperatively, were followed up for up to one year. Goode ratio and Nasofacial angle deducted from real time photographs have been used to evaluate the amount of rotation and deprojection of the nasal tip. Results: Overlapping of the Lateral Crura of the Lower Lateral Cartilages, is a safe and reasonable technic in achieving nasal tip rotation, with or without, projection reduction, of the droopy nose. The operative time and dissection are very encouraging. Complications associated with this technic are very negligible, with high patient satisfaction rates. Only five rhinoplasty patient has been revised for the sake of tip rotation/projection, in this series of cases. No Major complications happened in the collumellar skin incision or the nasal rim infracartilagenous incisions, nor in the undermined nasal vestibular skin separated from the undersurface of the Lower Lateral Cartilages. Conclusion: Overlapping, or overlaying, of the lateral crura of the lower lateral cartilages, is a reasonable technique to enhance tip rotation, and reduction of the tip projection, by medial crural steal and telescoping of the incised lower lateral cartilages, with good aesthetic and functional outcomes, with reasonable complication rates, very low revision rate, and high patient satisfaction rates.

The effect of lateral crural overlay surgical technique on elasticity of nasal ala.

The nasal tip refinement is the most difficult stages of rhinoplasty surgery; whereas, the most important part in terms of beauty and performance is the projection refinement. Lateral crural overlay (LCO) is a common technique in rhinoplasty used to reduce nasal tip projection and increase nasal tip rotation. Given the important role of lower lateral cartilage (LLC) in the non-collapse of nasal external valve and air passage, it is necessary to evaluate the changes in nasal elasticity caused by surgery. The design of this quasi experimental study was self-control (before-after). Tip plasty was performed on twenty-four samples (12 cases of rhinoplasty) using LCO technique. To examine the elasticity, the strain index of each ala was measured by a mechanical device, invented by the author, before and after the operation. Out of 24 samples 12 were female and 12 were male. The mean strain index of nasal ala before and after the surgery was 0.24 ± 0.046 and 0.19 ± 0.040 respectively (P < 0.001). The mean strain index of nasal ala before and after surgery for female was 0.27 ± 0.046 and 0.20 ± 0.050 respectively (P = 0.004). For male, it was 0.20 ± 0.018 before and 0.18 ± 0.020 after the surgery. (P < 0.001). Using LCO surgical technique for nasal tip refinement can lead to nasal elasticity increase regardless of gender; although, LLC is cut during implementing this technique.

Discussion: Septum-Based Nasal Tip Plasty: A Comparative Study between Septal Extension Graft and Double-Layered Conchal Cartilage Extension Graft.

Chicago, Ill. From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Illinois at Chicago. Received for publication July 23, 2017; accepted July 26, 2017. Disclosure:The author has no financial interest to declare in relation to the content of this Discussion or of the associated article. Dean M. Toriumi, M.D., Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Illinois at Chicago, 1855 W Taylor Street, Room 2.42, Chicago, Ill. 60612-7242

Cutting the Holy Dome: The Evolution of Vertical Alar Resection.

Dome division or vertical dome division (VDD) is a tip plasty technique that is effective when applied appropriately to suitable patients. For 15years, we have used VDD and made modifications as needed. In classical VDD, the dome area is cut and left to heal, but experience shows that additional components are needed to complement dome division, such as sutures or grafts. In this study, we retrospectively analysed our rhinoplasty patients in whom we used vertical alar resection (VAR) to assess the advantages and disadvantages of this technique. To our knowledge, this is one of the most exhaustive studies of VDD, including over 3000 patients. This retrospective case series reviewed the charts of 3965 patients who underwent VAR between 2000 and 2015. All patients were operated on by the senior surgeon. Dome division was used for various reasons, including a deformed tip area in revision rhinoplasties, droopy nose, wide tip, pinched nose, tip asymmetry, and overprojected nasal tip. Patients were excluded if they had septal deviation that enabled tip rotation, or a dorsum problem that caused tip asymmetry. The study included 3965 patients (3172 women and 793 men) who underwent open rhinoplasty from 2000 to 2015. The mean patient age was 28.3years (range 18-50years). The mean clinical follow-up duration was 11.2years. In conclusion, this technique is capable of modifying all parameters of the nasal tip (projection, rotation, and volume), as required, at the same time, addressing many tip problems. 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 .

Contracted Nose Correction with Dermofat and Conchal Cartilage.

Contracted Nose Correction with Dermofat and Conchal Cartilage.

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

Regarding septal fixation in nasal tip plasty, the nasal tip tripod theory may require modification. We performed three-dimensional (3D) photogrammetric analysis of the "Skiff graft," which is a quadripod method involving folded conchal cartilages fixated on the caudal septal angle, paired lateral crura reinforced by a derotational conchal cartilage graft, and conjoined medial crus on the columella base. We assessed the efficacy of the Skiff graft in maintaining tip projection and preventing cephalic rotation of the nasal tip. In total, 39 patients who underwent nasal tip plasty with the Skiff graft during 2012-2015 and underwent 3D photogrammetry before (T0), immediately postoperatively (T1, average of 1week postoperatively), and an average of 215days postoperatively (T2) were included. Nasal tip projection was objectively measured from images using a software program. The average differences between the T0 and T1, T0 and T2, and T1 and T2 lengths were 4.81, 3.57, and 0.85mm, respectively. Thus, 81% of the change in tip projection length that had been achieved immediately postoperatively was maintained at T2 based on 3D photogrammetry (P<0.001). The relapse ratio of the examined technique was 19.26% (mean, 0.85mm; P<0.001). Nasal tip plasty with the Skiff graft preserves septal support and is an effective primary and revision rhinoplasty technique in Asian patients. This approach may be suitable as an alternative to nasal tip plasty with the septal extension graft in terms of maintaining nasal tip projection, rotational controllability, and nasal mobility. 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 .

Outcomes of Open-Approach Extracorporeal Septoplasty Without Simultaneous Rhinoplasty: Effects on Nasal Tip Projection and Rotation.

Performing an open-approach extracorporeal septoplasty (OAES) without simultaneous rhinoplasty could have adverse effects. We sought to understand the effects of OAES without simultaneous rhinoplasty on nasal tip projection and rotation in patients with severe septal deviation. To evaluate the outcomes of OAES without simultaneous rhinoplasty in terms of nasal tip projection and rotation using objective measurements. This retrospective study was conducted at a training and research hospital using medical records of 32 adult patients who underwent OAES without simultaneous rhinoplasty between April 10, 2012 and June 12, 2015. Patients who underwent endonasal septoplasty, revision septal surgery, septorhinoplasty, open-approach septoplasty with nasal tip plasty, or open-approach septoplasty without removal of the entire septal cartilage were excluded from the study. Postoperative photographs of the patients were taken at a mean (range) time of 16.4 (6-36) months after surgery. Nasolabial angle (NLA), nasofacial angle (NFA), and projection index (PI) were measured by the same surgeon on preoperative and postoperative lateral images. Projection index was measured using the Goode method; NLA and NFA were measured drawing lines between specific facial points according to the literature. All measurements were compared statistically. Thirty-two adult patients (26 men and 6 women between ages 20 and 57 years) with severe septal deviation and underwent OAES without simultaneous rhinoplasty were included in the study. The postoperative values of NLA and NFA were observed to be decreased in all patients (100%). The PI was also determined to be decreased in 27 patients (84.6%) whereas it remained unchanged in 5 patients (15.4%). The overall postoperative mean values of NLA, NFA, and PI were found to be lower compared with preoperative mean values and the difference between them were determined to be statistically significant (NLA: 95% CI, 0.40-2.55, P = .005; NFA: 95% CI, 0.48-2.06, P = .003; and PI: 95% CI, 0.004-0.015, P = .002). This study reveals that the nasal tip lost height from facial plane and rotated caudally in most patients who underwent OAES without simultaneous rhinoplasty. Patients demanding only relief of nasal obstruction and scheduled for OAES have to be informed about the potential cosmetic alterations when a simultaneous rhinoplasty is not requested.

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

Clinical efficacy of M-shaped cartilage used in nasal tip cosmetic plasty

Objective To explore a new method of nasal tip plasty and its clinical effect, which is much accorded with biomechanical properties of the human body. Methods From June 2010 to March 2016, a total of 33 cases of nasal tip surgery, 6 males and 27 females, were performed. Ages ranged from 22 to 46 years in this group. Ear cartilage was trimmed into two strips and sutured them together in a M shape. When located to the original position of the nasal alar cartilage, the M shaped cartilage could be used in nasal tip; when fixing part of it on the nasal septum or lengthened nasal septal cartilage, the M shaped cartilage could be used in cosmetic surgery of nasal tip lengthening. Results The follow-up period was from one month to 60 months, with average 14 months. 29 patients (87.9%) were satisfied with the efficacy and 2 patients were suffered from infection (6.1%). Conclusions When the M-shaped cartilage is fixed with lengthened nasal septum, it can lengthen the nasal tip much more and the contouring and texture of nasal tip are better than that of using a shield or a cap cartilage graft. Key words: Nasal tip; Rhinoplasty; M-shaped cartilage

Freed Lower Lateral Cartilages with Intact Lateral Attachments: A Versatile Approach in Tip Plasty.

Tip plasty is an important procedure that contributes much to obtaining an aesthetically pleasant nose. To increase precision during the tip plasty procedure, control over the lower lateral cartilages should be maximized. This can be accomplished by extending the exposure of the cartilage framework. We present our "Freed Lower Lateral Cartilages With Intact Lateral Attachments" approach through which inferior lateral cartilages are being dissected free from their attachments, while only their lateral bases (lateral crural parts) are left intact. A total of 1752 consecutive patients operated on with this approach were included. All patients were cosmetic rhinoplasty patients operated on between the years 1999 and 2014. During tip plasty, the lower lateral cartilages of all patients were totally dissected from all their attachments, while the lateral bases were left intact. The suture and graft techniques for the tip plasty procedure were then applied to reconfigure the tip region. The approach was used successfully in 1752 patients in a 15-year period. The mean age of patients was 33.5years. The complication rate was 6.4% and the revision rate was 4.7% for the patients. Only 1.2% of patients needed a revision surgery for tip and/or alar region. None of these patients needed further revision. The aesthetic and functional outcomes revealed high satisfaction rates. The "Freed Lower Lateral Cartilages With Intact Lateral Attachments" approach in tip plasty facilitates manipulation of the tip region while maintaining precise control to provide definition in terms of symmetry and three-dimensional configuration. Furthermore, it constitutes an autologous and practical platform on which nondestructive techniques can be performed in a combined and synergistic fashion. 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 .

How can periorbital oedema and ecchymose be reduced in rhinoplasty?

Oedema and ecchymose are frequent morbidities of septorhinoplasty, a facial surgical procedure for reforming the shape and functions of the nose. Periorbital oedema (PO) and periorbital ecchymose (PE) are normal occurrences, but are undesirable for patients undergoing the procedure for aesthetic purposes. The present study examined 65 patients who underwent open technique septorhinoplasty for aesthetic and functional complaints. Patients were divided into two groups: Group 1 patients underwent lateral osteotomy following tip plasty, at the end of the surgical operation; Group 2 patients underwent lateral osteotomy before tip plasty, at the beginning of the surgical operation. Patients were followed on the postoperative first, third and seventh days. PO and PE values of patients were scored from 0 to 4. The plastering time (Pt) was significantly shorter for Group I than Group II (p<0.05). The total surgical time (T) showed no significant difference (p>0.05). The PO value at the first, third and seventh days was significantly smaller for Group I than Group II (p<0.05). The PE value at the first, third and seventh days was also significantly smaller for Group I than Group II (p<0.05). The obtained data indicate that performing a lateral osteotomy in the final stages of surgery, and subsequently applying a nasal plaster and splint as rapidly as possible, decreases PO and PE in the postoperative period.

Fibroareolar Tissue Wrap-Around Flap for Tip Plasty in Rhinoplasty in Asians

Background Asians tend to have bulbous, wide, and thick-skinned noses, leading to limitations in tip augmentation. Therefore, following various tip plasty procedures, the use of a dermal graft or a fat graft may be considered for additional augmentation. For definition of the Asian nasal tip, thick fibroareolar and subcutaneous tissues are resected. However, these previously discarded tissues may be a useful material for tip augmentation. Hence, we would like to propose the fibroareolar tissue wrap-around flap as an adjuvant augmentation procedure. Methods Tip plasty procedures, including various suture techniques and cartilage grafts, were performed. Near the scroll area, the fibroareolar tissues above both lower lateral cartilages were dissected in the supraperichondrial plane. Caudally based fibroareolar tissue flaps were elevated around the nasal tip. The tip portion of the alar cartilage framework was covered with the flaps. The flaps were fixed to the middle or medial crura of the lower lateral cartilages. Results A total of 13 patients underwent the fibroareolar tissue wrap-around flap procedure for nasal tip plasty. No complaints were reported at follow-up by 12 patients. No cases of major infection, hematoma, or vascular compromise occurred. Conclusions The fibroareolar tissue wrap-around flap offers several advantages for tip plasty in Asians, including additional tip projection, soft tissue volume reduction, redraping, and a naturally soft nasal tip, and likely aids in preserving the volume of other cartilage grafts. Therefore, this fibroareolar tissue wrap-around flap is worth considering as a useful adjuvant option for tip plasty in rhinoplasty in Asian patients. Keywords: Asian continental ancestry group, Rhinoplasty, Surgical flaps

Aesthetic Facial Correction of Cleidocranial Dysplasia.

We report two cases of cleidocranial dysplasia, which was managed without significant craniofacial osteotomy. A mother and daughter, both of normal intelligence, presented with central forehead depression, mid-face hypoplasia, and blepharoptosis. The fact that they have an identically deformed face implied a genetic basis. In both patients, radiologic evaluation revealed the underdeveloped maxilla, persistent fontanelle opening, and cleidal aplasia. Clinical findings and radiologic studies were consistent with the diagnosis of cleidocranial dysplasia. Both patients underwent forehead plasty via bicoronal approach, augmentation rhinoplasty using tip plasty, and epicanthoplasty. In addition, the mother underwent malar augmentation using Medpor implantation and reduction genioplasty. The patients did not experience any postoperative complication and remained satisfied with the operation at 6-year follow-up.

A Novel Technique for Short Nose Correction: Hybrid Septal Extension Graft.

There are many techniques for correcting short nose deformities and the septal extension graft is the most commonly performed technique among Asians. In many Asian patients septal cartilage, however, is too small and insufficient to perform an effective septal extension graft. Therefore, we designed a novel technique, named hybrid septal extension graft to overcome this pitfall in Asian tip plasty. From February 2010 to March 2013, 41 patients with primary (N = 30) or secondary (N = 11) short nose deformity underwent a hybrid septal extension graft. The hybrid septal extension graft is a modified septal extension graft which uses the small septal cartilage along with irradiated homologous costal cartilage. Irradiated homologous costal cartilage was carved into a shape of a thin batten and securely fixed bilaterally to the caudal septum. Harvested septal cartilage was located between the 2 irradiated homologous costal cartilage batten grafts and fixed with sutures. Then, the alar cartilage was fixed at the end of the septal cartilage graft. The nasal lengths, nasal tip projections, and nasolabial angles were measured pre- and postoperatively. The hybrid septal extension graft showed enough nose lengthening and a decreased nostril show, even in cases with a very small septal cartilage. The authors present a novel technique for correction of short nose deformity in Asians. The hybrid septal extension graft provides good results with minimal complications and overall patient satisfaction was very high.

Nasal Tip Plasty Using a Batten Graft with Ear Cartilage in East Asians

Nasal Tip Plasty Using a Batten Graft with Ear Cartilage in East Asians

Value of cephalic part of lateral crus in functional rhinoplasty.

Reshaping of the nasal tip is the most difficult part of rhinoplasty. Over the years, there have been many advances in the field of rhinoplasty, including tip plasty. The goal of these continuous refinements in existing procedures has been to improve both aesthetic and functional outcomes. The cephalic part of the lateral crus of the lower lateral cartilage is what mainly contributes to nasal tip deformity. Various surgical techniques have been reported that used the cephalic part of lateral crus to refine the nasal tip and preserve alar integrity and nasal breathing function. In this review article, we have attempted to show the evolution of these methods while focusing on development of approaches that are basic for "modern rhinoplasty" and presenting our personal preferences. We have also endeavored to categorize these methods and clarify some misconceptions and inaccuracies in their descriptions.

Dorsal Nasal Augmentation: Is the Composite Graft Consisting of Conchal Cartilage and Retroauricular Fascia an Effective Option?

Augmentation of a deficient nasal dorsum remains a challenge in rhinoplasty. Different methods and materials have been described in the literature. The purpose of this study was to present the authors' experiences using a composite graft consisting of conchal cartilage and retroauricular fascia for dorsal augmentation. Patients with moderate to severe dorsal deficiencies were included in this study. The postauricular sulcus was used to gain access to the auricular cartilage and the retroauricular fascia. If the dorsal deficiency was moderate, then 1 layer of conchal cartilage was used. In more severe deficiencies, the cartilage pieces were superimposed, and a multilayer conchal graft was used. To fix the cartilage segments to each other, 6-0 polydioxanone (PDS) suture was used. Then, the cartilage segment was fixed to the retroauricular fascia with 6-0 PDS suture. The nasal dorsum was undermined carefully to create adequate space for chondrofascial graft placement. After performing required maneuvers for solving the functional disorders, tip plasty, and the lateral nasal wall osteotomy, the prepared chondrofascial graft was placed in the dorsal pocket. Fourteen patients (5 men and 9 women) participated in this study. The average follow-up duration was 25.4 months (range, 16 to 42 months). The patients' age ranged from 14 to 54 years (average, 25.9 yr). Follow-up showed no cases of infection, hematoma, major graft resorption, asymmetric graft resorption, and displacement of grafts. No postoperative scars were visible at the donor sites. Mild to moderate ecchymosis occurred at the donor sites in 8 patients, which were solved after 10 days without any complications. In 3 male patients, slight graft resorption was noted. The esthetic results were not compromised in these patients, and revision surgery was not performed. This small series of cases with relatively adequate follow-up showed that a composite graft consisting of conchal cartilage and retroauricular fascia is a reliable technique for nasal dorsal augmentation in patients with moderate to severe dorsal deficiency.