Decreasing nasal tip projection in rhinoplasty.

BACKGROUND: Decreasing nasal tip projection is occasionally required in rhinoplasty and requires a working knowledge of nasal support and function. Equally important is an understanding of the evolution to a more conservative and incremental approach when decreasing nasal tip projection. Such a conservative approach reserves the most aggressive and precarious maneuvers to be used only when absolutely required. METHODS: The authors review the history and evolution of techniques regarding decrease in nasal tip projection. Anatomy of the nasal tip with focus on tip support structures is reviewed. Distinguishing between pseudo-overprojection and true overprojection of the nasal tip is discussed. Methods of diagnosing nasal tip projection are reviewed and a suggested surgical approach is presented. RESULTS: Reduction of nasal tip projection requires a thorough knowledge of relevant anatomy and tissue interplay. Although a variety of techniques and algorithms exist in addition to those recommended in this article, the goal should be an incremental approach with constant reassessment. Tip truncation is rarely if ever indicated and is often associated with eventual contour deformity. CONCLUSION: The described approach in this article has been proven reliable for the vast majority of patients undergoing rhinoplasty with the overprojected nose.

Secondary rhinoplasty and the use of autogenous rib cartilage grafts.

Postoperative rhinoplasty deformities--such as displacement or distortion of anatomic structures, inadequate surgery resulting in under-resection of the nasal framework, or over-resection caused by overzealous surgery--require a secondary rhinoplasty. Success in secondary rhinoplasty, therefore, relies on an accurate clinical diagnosis and analysis of the nasal deformities, a thorough operative plan to address each abnormality, and a meticulous surgical technique. Septal cartilage is the grafting material of choice for rhinoplasty; however, auricular cartilage and rib cartilage are used in secondary rhinoplasty. This article discusses the steps involved in the external approach to secondary rhinoplasty.

Lower lateral crural turnover flap in open rhinoplasty.

BACKGROUND: Lower lateral crural deformities are common problems in rhinoplasty. The shape and position of the lower lateral crura directly influence the alar contour and external valve function. This study reviews an extensive experience with the lower lateral crural turnover flap, which represents a versatile and reproducible technique for correction of lower lateral crural deformities and improvement of external valve function. METHODS: A retrospective review of our experience with the lateral crural turnover flap in consecutive primary (n = 21), secondary (n = 2), and tertiary (n = 1) open rhinoplasties was conducted to evaluate the indications, contraindications, and long-term outcomes of this technique. Patient case examples are used to illustrate this technique and its results. RESULTS: The lower lateral crural turnover flap is beneficial for deformities, weakness, and collapse of the lower lateral crura. It can also be used to improve lower lateral crural strength during tip reshaping. It is contraindicated when there is insufficient width of the lower lateral crura. A lower lateral crural turnover flap can complement other external valve and alar arch supporting techniques, such as placement of alar contour grafts and/or alar batten grafts. The shape and position of the lower lateral crural turnover flaps have had long-lasting results (>1 year) after open rhinoplasty. CONCLUSIONS: The lower lateral crural turnover flap is a useful and reproducible technique in rhinoplasty with enduring results. The use of adjacent cartilage provides a local source of viable tissue to correct and support the lower lateral crura in both primary and revision rhinoplasty.

Harvesting rib cartilage grafts for secondary rhinoplasty.

BACKGROUND: Reconstruction of the nasal osseocartilaginous framework is the foundation of successful secondary rhinoplasty. METHODS: Achieving this often requires large quantities of cartilage to correct both contour deformities and functional problems caused by previous procedures. Satisfactory and consistent long-term results rely on using grafts with low resorption rates and sufficient strength to offer adequate support. Auricular cartilage, irradiated cartilage, and alloplastic materials have all been used as implantable grafts with limited success. RESULTS: In the senior author's experience (J.P.G.), rib cartilage has proven to be a reliable, abundant, and relatively accessible donor with which to facilitate successful secondary rhinoplasty surgery. CONCLUSIONS: : The authors describe in detail the techniques that they have found to be integral in harvesting rib cartilage grafts for secondary rhinoplasty.

Dorsal augmentation with autogenous rib cartilage.

Reconstruction of the nasal osseocartilaginous framework is the foundation of successful primary and secondary rhinoplasty. When adequate septal cartilage is unavailable, the rib provides the most abundant source of cartilage for graft fabrication and is the most reliable when structural support is needed. We present the senior author's (J.P.G.) experience and evolution of techniques of dorsal augmentation with autogenous rib cartilage grafts with internal K-wire stabilization in rhinoplasty.

Frequently used grafts in rhinoplasty: nomenclature and analysis.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Accurately name the most frequently used grafts in primary and secondary rhinoplasty. 2. Describe the precise anatomical position of each graft. 3. Discuss the clinical indications of each graft. SUMMARY: In this article, the authors present the grafting techniques most commonly used to sculpt the nasal framework in primary and secondary rhinoplasty. The grafts are described in terms of their nomenclature, anatomical location, and clinical indications, presenting a simple and easy-to-reference guide for both beginners and expert surgeons.

Management of intraoperative fractures of the nasal septal "L-strut": percutaneous Kirschner wire fixation.

BACKGROUND: The area where the septal cartilage joins the perpendicular plate of the ethmoid is a vulnerable region where overresection or disruption during rhinoplasty causes a loss of support and potential collapse of the nasal dorsum, leading to a saddle-nose deformity. Previously described methods of repair involve suture techniques that are often inadequate to restore septal stability. The authors present the senior author's (J. P. G.) experience in managing intraoperative fractures of the septal "L-strut," describe a classification system for the types of dorsal septal L-strut fractures, and present a new method of treatment using percutaneous Kirschner wire fixation. METHODS: The authors conducted a retrospective review of 1372 primary and secondary rhinoplasties performed by the senior author. A classification system was developed to describe the type and location of dorsal septal L-strut fractures. Each patient was treated with immediate restabilization of the fractured dorsal septal L-strut with dorsal spreader grafts, percutaneous Kirschner wire fixation, or a combination of both methods. RESULTS: Seventeen patients sustained an intraoperative fracture of the septal L-strut with an overall incidence of 1.2 percent. Complications included minor dorsal deviation and inadequate reduction/moderate dorsal depression in three patients requiring revision surgery to correct the dorsal deformities. CONCLUSIONS: An intraoperative fracture of the septal L-strut is a rare but unfortunate occurrence during rhinoplasty. Although technically difficult to perform, the percutaneous Kirschner wire fixation technique with or without spreader grafts is a novel and effective approach to this complication.

The tripod concept for correcting nasal-tip cartilages.

In treating nasal-tip deformities, the authors use the tripod concept to anatomically simulate the paired lower lateral cartilage complexes. They recommend using rib cartilage to obtain predictable and reproducible results.

The deviated nose: optimizing results using a simplified classification and algorithmic approach.

The deviated nose presents a particular challenge to the rhinoplasty surgeon because, frequently, both a functional problem (airway obstruction) and an aesthetic problem must be addressed. An approach to the deviated nose is presented that relies on accurate preoperative planning and precise intraoperative execution of corrective measures to return the nasal dorsum to midline, restore dorsal aesthetic lines, and maintain airway patency. The principles of correction include wide exposure through the open approach, release of all deforming forces to the septum, straightening of the septum while maintaining an adequate dorsal and caudal strut, restoring long-term support, reducing the hypertrophied turbinates, and performing controlled stable percutaneous osteotomies. An operative algorithm is described that emphasizes simplicity and reproducibility, and case studies demonstrate the results that can be achieved with this approach.

Digital photography for rhinoplasty.

Standardized, high-quality, preoperative photographs of the nose are critical for preoperative rhinoplasty planning, comparative postoperative assessment, and demonstration of surgical results. To produce these high-quality, reproducible photographs, it is essential to standardize lighting, to properly position the patient in standard views, to avoid lens distortion, and to maintain consistent camera-to-subject distances. Traditional photographic standards have been well documented in the literature; however, most do not address digital photography, and none address digital photography for rhinoplasty. Certain variables in digital photography that are not present in 35-mm photography can be critical to the appearance of the final image. Variables such as image color and contrast (which usually vary between digital cameras), focal length differences between 35-mm and most digital cameras, the effect of resolution and compression on image quality, and the effect of the printing method used can affect the appearance of the external anatomy of the nose in the final print or image. Lack of detail in the external nasal anatomy becomes an issue if the surgeon uses the photograph intraoperatively for reference, as the authors do. Initially, the authors experienced difficulties with observing subtleties in the tip-defining points and tip anatomy using digital photography when compared with our traditional methods of 35-mm photography. The lack of detail in the external anatomy was most prevalent in the frontal and basal views. Thus, the authors have since tailored their photographic methods to document the rhinoplasty patient to maximize the visual information of the external nasal anatomy in the photographic and the printed image. This article is intended to review the photographic principles for standardized rhinoplasty photography, address the additional considerations necessary when using digital photography, discuss the printing variables that can affect overall quality of the printed image, and discuss the authors' new method of photographing the rhinoplasty patient.