Total Lower Lateral Cartilage Reconstruction in Multiple Revision Rhinoplasty Patients.

OBJECTIVE: The aim of this study is to demonstrate a novel surgical technique of total lower lateral cartilage reconstruction using costal cartilage grafts in multiple revision rhinoplasty cases. METHOD: Total lower lateral cartilage reconstruction technique was utilized in 24 patients who underwent open technique septorhinoplasty between 2019 and 2023. Fourteen of the patients were female, and 10 were male. In this technique, we performed total lower lateral cartilage reconstruction in multiple revision cases where the support of both medial and lateral crura was poor. In cases where only the medial crus or only the lateral crus support was inadequate, we performed reconstruction only for the poorly supported portion. A new lower lateral cartilage was created with grafts obtained from the costal cartilage. RESULTS: The mean age of the patients was 23. The mean follow-up time of the patients was between 6 and 18 months. No complications were observed due to this technique. Satisfactory results were obtained in the postoperative period after surgery. CONCLUSION: Multiple revision rhinoplasties present significant difficulties due to complicated nasal anatomy and weakened lower lateral cartilages. We have shown that successful results can be achieved in these complex cases with total lower lateral cartilage reconstruction using costal cartilage grafts. LEVEL OF EVIDENCE IV: 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.

Use of lateral alar caudal graft to increase nasal tip definition in rhinoplasty.

OBJECTIVE: The aim of this study is to demonstrate use of Lateral Alar Caudal Graft to increase nasal tip definition in primary or revision rhinoplasty cases. METHOD: Lateral Alar Caudal Graft was used in 24 patients who underwent open technique septorhinoplasty between 2019 and 2023 years. Fourteen of the patients were female and 10 were male. This technique was applied in revision or primary cases where the caudal part of the lateral alar crura of the lower lateral cartilage was lower in the vertical plane than the cephalic part. The Lateral Alar Caudal Graft was sutured over the caudal edge of the lateral alar crura of the lower lateral cartilage. RESULT: The mean age of the patients was 23. The mean follow-up time of the patients was between 6 and 18 months. No complications were observed due to this technique. Satisfactory results were obtained in the postoperative period after surgery. CONCLUSION: We have successfully demonstrated that in primary or revision rhinoplasty cases, nasal tip definition will be enhanced by positioning the caudal level of the lateral alar crura of the lower lateral cartilage higher than the cephalic level using an onlay lateral alar crural graft and eliminated the need for alar rim graft.

A New Technique for Use Instead of Lateral Crural Overlay for Reduction of Nasal Tip Projection in Revision Rhinoplasty.

Objective: Correction of nasal tip projection (NTP) deformities involve techniques for the lower lateral cartilage of the nose. Previously, it would have been surgically difficult to perform the lateral crural overlay (LCO) technique for the second time in revision rhinoplasty in patients who already had undergone rhinoplasty with the LCO technique because of the length of the NTP. In this study, we evaluated the lateral crural segmental excision (LCSE) technique in patients with overprojected nasal tip in revision rhinoplasty. Methods: We retrospectively studied the cases of 19 patients who had initially undergone rhinoplasty with the LCO technique for overprojected nasal tip, and later underwent revision rhinoplasty with the LCSE technique after insufficient NTP was observed on facial analysis between 2018 and 2022. Results: Of the patients, 12 (63%) were male, with an average age of 29.6 years, and 7 (17%) patients were female, with an average age of 25.3 years. Using Goode's formula, NTP indexes of patients measured 79.4±1.8 preoperatively and 56.0±1.3 postoperatively. Stastically significant difference was observed between preoperative and postoperative values. None of the patients had malnutrition at the incision margins, and all patients recovered on time and without any problems. Granulation tissue was detected in the mucosa in only one patient. Conclusion: The LCSE technique, with a short surgical time, recovery period without complications, and satisfactory nasal respiratory function, is preferred over a second LCO application in cases of NTP.

A Single Stage Composite Cleft Septorhinoplasty for Correction of the Mature Unilateral Cleft Nose Deformity - The Gujrat Technique.

OBJECTIVE: To evaluate the results of a single stage composite cleft septorhinoplasty procedure ("The Gujrat Technique") to correct the exaggerated cleft nose deformity after completion of nasal growth in an adult patient cohort. METHODS: Adult patients with a residual unilateral cleft nasal deformity were deemed eligible for the proposed "Gujrat Technique". Over a 10-year period (2007-2017), 96 adult patients underwent this composite cleft septorhinoplasty as a single stage operation. Post-operative nasal symmetry evaluation was undertaken using the validated computer program 'SymNose'. Functional outcome and patient satisfaction were assessed using Nasal Obstruction Symptom Evaluation scale and Rhinoplasty Outcome Evaluation (ROE) questionnaires respectively. Various statistical analysis methods were used to validate the obtained results. RESULTS: Due to poor compliance with follow-up, post-operative assessments were undertaken in only 32 patients. The single group study design using the non-parametric matching pairs Wilcoxon Sign test (p < 0.001) showed overall good to excellent functional and aesthetic outcomes and higher scores of the digital SymNose grading system. There was a significant improvement in ROE scores (from 26.4 ± 2.9 to 85.9 ± 4.7, p < 0.001). There were no major complications or revisions needed in our series. CONCLUSION: The individual components of "The Gujrat Technique" are not novel but their combination in this adult unilateral cleft rhinoplasty cohort has demonstrated a high patient satisfaction with its aesthetic appeal and functional versatility. In the background of limited resources and unpredictable patient follow up, the simplicity, reproducibility and cost effectiveness of this technique make it a practical reconstructive option.

A Rare Case of Isolated Congenital Aplasia of Right Lower Lateral Cartilage with Its Aesthetic Correction and Literature Review.

The congenital non-syndromic nonfamilial isolated absence of nasal structure is exceedingly rare. In this article, we present the sixth case of isolated aplasia of lower lateral cartilage. We have discussed the new technique of reconstruction, reviewed the literature regarding origin of pathology at embryonic level and repair techniques used by different authors.

Congenital hypoplasia and aplasia of different segments of medial crus: A case report.

INTRODUCTION: Congenital anomalies of lower lateral cartilages are very rare. Difficulties to detect before the operation may cause problems during the surgery. In this paper, we presented a unique deformity with the combination of aplastic and hypoplastic segments of lower lateral cartilage. METHODS: A 21-year-old female patient who underwent rhinoplasty were enrolled in this study. Airway impairment, prominent nasal hump, droopy nasal tip and nostril asymmetries were observed in physical examination. RESULTS: Partial aplasia and hypoplasia on the right-sided lobular segment and hypoplasia on the left-sided lobular segment of the middle crus were detected. Hypoplasia of the columellar segment and footplate segment of the medial crus was observed on both sides. Also, intercrural soft tissue volume was low. Defective medial crus was reconstructed with the septal cartilage graft. CONCLUSION: Although a rare occurrence, awareness of congenital lower cartilage anomalies is important for surgical planning and reconstruction of deformities. Cartilage tissue reflection to the skin surface and examination of each tip segment is crucial to detect anomalies preoperatively. LEVEL OF EVIDENCE: 4 (Therapeutic).

Isolated Congenital Absence of Right Lower Lateral Cartilage and Reconstruction with Septal Cartilage: A Case Report and Review of Literature.

Congenital anomalies of the nose are rare but may be associated with syndromes affecting craniofacial structures. Herein, we report a case of a congenital absence of lower lateral cartilage seen during an open rhinoplasty in a 23-yr-old lady with no underlying health conditions. Medical and surgical history were unremarkable and there were no evidences conducted of any previous traumatic facial injuries. During physical examination, a significant nostril asymmetry was noted to be present. In addition, cotton test showed no evidence of obstruction. The absence of lower lateral cartilage on the right side was noted during the degloving stage of the open rhinoplasty. Absence of lower lateral cartilage poses a technical challenge in surgery and in order to reconstruct this structure, cartilage can be harvested from concha, lower lateral cartilage, septum and cartilaginous dorsal hump during an open approach rhinoplasty.

Correction of secondary unilateral cleft lip nasal deformity in adults using lower lateral cartilage repositioning, columellar strut, and onlay cartilage graft on the nasal tip with open rhinoplasty combined with reverse-U incision.

A rhinoplasty technique involving lower lateral cartilage (LLC) repositioning and grafting of ear cartilage allows for nasal lengthening and nasal tip mobility. For better esthetic outcomes in patients with cleft lip nasal deformity (CLND), we combined cosmetic nasal tip plasty with standard techniques. We performed open rhinoplasty combined with reverse-U incision and V-Y plasty in 62 patients with secondary unilateral CLND from October 2013 to June 2018. Both LLCs were isolated, repositioned, approximated medially, and advanced with a Medpor strut, followed by tip suture technique. To further project and enhance the nasal tip and columella, application of ear cartilage onlay graft was used. As adjunctive procedures, septoplasty or osteotomy was carried out for correction of septal or nasal bone deviations, respectively. Photogrammetric evaluations of patients and statistical analyses were performed. Average age at operation was 23.5 years (range: 18-42 years). Of the 62 patients, 15 underwent dorsal augmentation with silicone implant. Two-layer conchal cartilage onlay grafting was performed to manage tip height. Outcomes in 34 patients were analyzed with pre- and postoperative photography. Nasal tip projection increased, alar base width index decreased, and alar and columellar symmetry significantly improved. No Medpor implant exposure or other adverse outcomes occurred. The proposed technique is effective for correcting secondary unilateral CLND and achieving a satisfying nasal appearance in adults.

Posterior Cephalic Soft Triangle of the Nose: Surgical Implications.

BACKGROUND: The posterior cephalic soft triangle is formed between the posterior cephalic border of the lower lateral cartilage, posterior caudal border of the upper lateral cartilage, and the caudal edge of the nasal bone. PCST is an important component of the external nasal valve which provides resistance against dynamic collapse. OBJECTIVES: The objective of this study was to describe the anatomy of the PCST and to demonstrate its anatomic variations, dynamic interplays, and surgical implications. METHODS: A retrospective review was conducted of 310 primary and 42 secondary cases who underwent extended open approach rhinoplasty by the first author. The structures that create the PCST of the nose were preserved unless resection/displacement of them was absolutely necessary. Whenever an external nasal valve pathology was found, it was corrected with one or combination of the following maneuvers: triangular PCST onlay graft, caudal bone outfracture, alar rim graft, lateral crural strut graft. RESULTS: Twenty-four non-consecutive cases were identified in which PCST was intraoperatively confirmed to be weak or deformed. The most common pathology in the PCST was overresection of the posterior segments of the LLC during primary surgery (54.1%), followed by en bloc medialization of the PCST (33.3%). Triangular onlay grafting of the PCST was the most common corrective surgical intervention (83.3%), followed by corrective lateralization of caudal edge of nasal bone (29.1%). External valve function has been restored in 21 (87.5%) cases. CONCLUSIONS: PCST of the nose is an important anatomic landmark which has esthetic and functional significance in rhinoplasty. LEVEL OF EVIDENCE IV: 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 .

Scroll Ligament Preservation and Improvement in Nasal Tip with the Room Concept.

INTRODUCTION: In rhinoplasty operations, concavity and convexity have a particular place in terms of aesthetic and functional problems. To fix the problems associated with concavity and convexity, several techniques were reported for straightening of the lower lateral cartilage (LLC). The scroll ligament and its associated tissues can be preserved, and a better nasal tip can be obtained after the surgery. The purpose of this research is to present a new, more comfortable and more practical technique to overcome the problems associated with LLC. METHODS: The records of 190 patients who were operated on with this novel technique were assessed retrospectively. In the present "superior-based sliding flap" technique, the LLC remained thick and stable; therefore, a particular functional improvement was achieved. Additionally, the scroll ligament was preserved, so this technique prevented the accumulation of skin at the nose tip. Patients were evaluated using the "Rhinoplasty Outcome Evaluation" (ROE) 12 months after the surgery. RESULTS: The median patient age was 24.3 years. Among 190 patients, 23 were male (12.1%) and 167 were female (87.9%). All patients included in the study completed the ROE questionnaire. Patient satisfaction was excellent, registering at 95% of the included cases. In the assessment of nasal obstruction, it was found that the patients' patency score increased to 8.8 from 6.2 (out of 10) after the 12-month follow-up (p < 0.001). Revision surgery was not needed in any patient. CONCLUSION: The ability to have control over the LLC for all shapes via suturing two different points together is a noteworthy benefit of this technique. This is a safe, controlled and easily applicable technique that can be applied to generally every patient without the need for additional grafts. LEVEL OF EVIDENCE IV: 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.

Nasal Chondrosarcoma of the Lower Lateral Cartilage.

Head and neck chondrosarcomas are incredibly rare with documented cases arising from skull base, maxilla, larynx, and nasal septum. We present the first reported case of chondrosarcoma arising from the lower lateral cartilage of the nose treated with surgical resection and primary reconstruction.

How to perform subperichondrial and subperiosteal rhinoplasty.

Rhinoplasty, via either an open or a closed approach, is classically performed in the supraperichondrial plane, i.e. underneath the SMAS. Total subperichondrial and subperiosteal approaches, providing large exposure of all of the osteocartilaginous framework of the nose, have been described in recent years. This deeper dissection requires adaptation of surgical instruments to perform both subperichondrial and subperiosteal dissection, but also to perform osteotomies. New tools, such as the Rhinosculpture or piezoelectric motor are particularly useful in this context. Acquisition of this dissection technique, although it requires a long learning curve, is largely rewarded by the advantages of this technique in primary and secondary rhinoplasty. The objective of this technical note is to provide a detailed description of the operative technique and the instrumentation required.

Anthropometric Overview of Lower Alar Cartilage: An Indian Perspective.

The anatomy of the lower lateral cartilage varies according to the ethnicity of the patient. Considering that the manipulation of the lower lateral cartilage has become more prevalent in Indian rhinoplasties, understanding the comprehensive anatomy is of utmost importance. The aim of this descriptive study was to evaluate the anthropometric and morphological variations of the lower lateral cartilage in Indian noses and to compare this data from studies of various ethnic groups. Seventy lower lateral cartilages of thirty-five patients of Indian origin who underwent primary open rhinoplasty were dissected and assessed intraoperatively. There was no previous history of nasal trauma. The medial, middle and lateral distances from the caudal border of the alar cartilage to the alar rim were measured. Morphology of the cartilage was assessed. The results were analysed and comparison were made between the genders and various ethnic groups. A statistically significant difference (p < 0.05) was observed in terms of length, width, distance from the alar rim, compared to the other study. Convex type (56%) of lateral crura was most commonly seen, with no significant gender difference. This study highlights the anatomical differences among various ethnic groups and stresses the need to be aware of the complexities of the anatomical aspect of the cartilage, to avoid complications and provide acceptable aesthetic result to the patient.

Repositioned lateral crural flap technique for cephalic malposition in rhinoplasty.

BACKGROUND: Cephalic malposition of the lower lateral cartilage (CMLLC) is a relatively common anatomical variant, particularly in Middle Eastern patients. The characteristics of CMLLC include long alar creases, a boxy and ball-shaped nasal tip, parenthesis tip deformity and external valvular incompetence. The gold standard for correcting CMLLC is the lateral crural strut graft (Gunter graft), but many patients experience problems after this technique. OBJECTIVE: To evaluate the efficacy of the repositioned lateral crural flap (RLCF) technique in correcting CMLLC, and to discuss the cosmetic and functional results. METHODS: In the present study, 123 primary septorhinoplasty operations using the RLCF technique were performed between May 2012 and March 2013. The mean follow-up period was 11.4 months (range nine to 24 months). Four parameters were measured and compared pre- and postoperatively: the angle between the line connecting the maximum convexity of the lower lateral cartilage (LLC) to the tip-defining point and midline on each side (angle of rotation); the total distance between the maximum convexity of LLC right and left to midline (representing the size of the parenthesis deformity); satisfaction scale rating of the patients' nasal tip appearance; and the satisfaction scale rating of patients' breathing through their nostrils. RESULTS: The mean angle of the LLC to the midline significantly increased and the mean distance between the maximum convexities was significantly reduced, indicating correction of the malposition and reduction of the parenthesis deformity, respectively. The mean satisfactory scale ratings of nasal tip appearance and breathing quality were also significantly improved. CONCLUSION: CMLLC can be corrected using the RLCF technique, resulting in both aesthetic and functional improvements.

HISTORIQUE: La déviation céphalique des cartilages alaires (DCCA) est une variante anatomique relativement courante, particulièrement chez les patients moyen-orientaux. Ses caractéristiques sont de longs plis alaires, une pointe nasale carrée et bulbeuse, un aspect en parenthèse de la pointe et une incompétence valvulaire externe. La greffe de l'étai des crus latérales (greffe de Gunter) est la norme pour corriger la DCCA, mais de nombreux patients éprouvent des problèmes par la suite. OBJECTIF: Évaluer l'efficacité de la transposition des crus latérales (TCL) pour corriger la DCCA et en présenter les résultats esthétiques et fonctionnels. MÉTHODOLOGIE: Dans la présente étude, les chirurgiens ont effectué 123 opérations de septorhinoplastie primaire entre mai 2012 et mars 2013 par TCL. Ils ont assuré un suivi moyen de 11,4 mois (plage de neuf à 24 mois). Ils ont mesuré et comparé quatre paramètres avant et après l'opération : l'angle entre la ligne reliant la convexité maximale des cartilages alaires (CA) à la projection de la pointe et la portion médiane de part et d'autre (angle de rotation), la distance totale entre la convexité maximale du CA de part et d'autre de la portion médiane (correspondant à la mesure de l'aspect en parenthèse de la pointe), l'échelle de satisfaction des patients à l'égard de l'apparence de leur pointe nasale et l'échelle de satisfaction à l'égard de leur respiration nasale. RÉSULTATS: L'angle moyen entre les CA et le plan médian augmentait considérablement et la distance moyenne entre les convexités maximales diminuait de manière significative, confirmant respectivement que la déviation était corrigée et que l'aspect en parenthèse était réduit. L'échelle de satisfaction révélait également des évaluations moyennes beaucoup plus positives de l'apparence de la pointe nasale et de la qualité respiratoire. CONCLUSION: Il est possible de corriger la DCCA par TCL et d'ainsi obtenir des améliorations à la fois esthétiques et fonctionnelles.

Nasal Sculpting: Calculated and Predictable Tip Elevation With Cephalic Trim.

BACKGROUND: Rhinoplasty techniques to affect nasal tip rotation are well described. Cephalic alar trim is a powerful method for achieving tip elevation. Previous studies and texts provide aesthetic guidelines for nasolabial angles. Often, surgeon experience determines the degree of lower lateral cartilage resection to achieve optimal results. This study analyzes the change in tip elevation with measured resections of the lower lateral cartilages. This can aid the surgeon in accurately predicting the effect of cephalic alar trim on tip elevation. METHODS: Ten fresh cadaveric dissections were performed to determine the change in nasolabial angles after cephalic trim of the lower lateral cartilage. Closed rhinoplasty technique was performed using marginal and intercartilaginous incisions to expose the lower lateral cartilage. Caliper measurements of the lower lateral cartilage were recorded. Serial cephalic trim was performed in 25% increments. True lateral photographs were obtained before and after each serial excision. Nasolabial angle measurements were obtained using a digital goniometer for digital photo analysis. RESULTS: Four female and 6 male cadavers were evaluated. The mean initial nasolabial angle was 106° ± 2°. The mean lower lateral cartilage width was 9.45 ± 1.38 mm. Serial 25% reductions in lower lateral cartilage height resulted in a mean total nasolabial angle change of 7.4°, 12.9°, and 19.6°, respectively. The mean incremental change in the nasolabial angle was 6.47° ± 1.25°. CONCLUSION: The nasolabial angle is an essential aesthetic feature. Cephalic trim is a key maneuver in affecting the nasolabial angle. A 25% lower lateral cartilage cephalic trim correlates with an average change in the nasolabial angle of 6.47°. Knowledge of the cephalic trim to nasolabial angle relationship aids in achieving desired tip elevation.

Lateral crural repositioning for treatment of cephalic malposition.

After completion of this article, the reader should be able to describe the indications for lateral crural repositioning, understand the key steps to performing the procedure, and be able to manage the complications associated with this treatment strategy.