Lateral Crural Repositioning: Implications on Nasal Function.

There are many concepts for surgical management of the nasal tip with varying outcomes on esthetics and nasal function. Nasal tip surgery can influence nasal function based on how the techniques can alter lateral wall integrity. A retrospective chart review of rhinoplasty patients undergoing lateral crural strut grafting (LCSG) with and without repositioning from 2009 to 2017 of the primary author (D.M.T.) was performed. Preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE) scores were analyzed. In our study, 832 subjects were evaluated. The mean preoperative NOSE score of all subjects was 35.48. The longest follow-up mean was 652.07 days with a mean NOSE score of 7.07 (p < 0.0001). In the LCSG group, the mean preoperative NOSE score was 22.97. The longest follow-up mean was 583.29 days with a mean NOSE score of 7.22 (p < 0.0001). In the LCSG with repositioning group, the mean preoperative NOSE score was 43.42. The longest follow-up mean was 692.36 days with a mean NOSE score of 7.60 (p < 0.0001). LCSGs with or without repositioning improves nasal function showing significant improvement in NOSE scores. The use of these techniques require adhering to several technical points to maximize outcomes and to avoid deformity.

Advanced Preservation Rhinoplasty in the Era of Osteoplasty and Chondroplasty: How Have We Moved Beyond the Cottle Technique?

BACKGROUND: Over the last 10 years, many new papers on innovative strategies from different surgeons worldwide have elevated the philosophy of preservation rhinoplasty (PR) to a different level: advanced preservation rhinoplasty. OBJECTIVES: The goal of this article was to illustrate how 4 experienced surgeons approach important anatomical and functional issues related to PR. METHODS: M.G.F., A.M.K., B.S., and D.M.T. were asked about how they approach classical problems and relative contraindications for dorsal PR with different modern advanced preservation rhinoplasty techniques. RESULTS: The answers of each surgeon make clear a new reality in dorsal PR that did not exist in the recent past. These advances in dorsal PR techniques are due to many surgeons' contributions, leading this practice to a different level: advanced preservation rhinoplasty. CONCLUSIONS: Dorsal preservation is making a dramatic resurgence and is fueled by the many very talented surgeons who are demonstrating outstanding outcomes with preservation techniques. The authors believe that this trend will continue, and a mutual collaboration between structuralists and preservationists going forward will continue to advance rhinoplasty as a specialty.

Correction of the Saddle Nose Deformity Using the "Push Up" Technique.

The saddle nose deformity typically occurs after the loss of underlying septal support with loss of projection of the middle nasal vault. This creates a saddling effect as the upper lateral cartilages contract and forms a dip in the profile. The saddle nose deformity can occur from many different etiologies, including septal hematoma, fracture of the septum after trauma, disruption of the dorsal L-strut support after septoplasty, and metabolic disorders resulting in the loss of septal support. In most cases, the nasal bones remain in their native position creating a discrepancy in dorsal height and deformity. Correction of the saddle nose deformity can be performed using one of the two primary approaches. The most basic option is to simply fill the defect with a cartilage onlay graft (solid graft, diced cartilage and fascia, and so on) to create a normal dorsal line. This approach can be effective in many cases. Over time, the onlay graft may descend and create deformity or become visible. The other approach involves opening the middle nasal vault, placing spreader grafts, and reconstituting the dorsal L-strut, performing septal reconstruction or extracorporeal septoplasty. In this paper, we present our technique of repairing the saddle nose deformity using a "push up" method that preserves the middle vault anatomy and reconstitutes the proper projection of the middle-third of the nose.

Correction of the Saddle Nose Deformity Using the "Push Up" Technique.

The saddle nose deformity typically occurs after the loss of underlying septal support with loss of projection of the middle nasal vault. This creates a saddling effect as the upper lateral cartilages contract and forms a dip in the profile. The saddle nose deformity can occur from many different etiologies, including septal hematoma, fracture of the septum after trauma, disruption of the dorsal L-strut support after septoplasty, and metabolic disorders resulting in the loss of septal support. In most cases, the nasal bones remain in their native position creating a discrepancy in dorsal height and deformity. Correction of the saddle nose deformity can be performed using one of the two primary approaches. The most basic option is to simply fill the defect with a cartilage onlay graft (solid graft, diced cartilage and fascia, and so on) to create a normal dorsal line. This approach can be effective in many cases. Over time, the onlay graft may descend and create deformity or become visible. The other approach involves opening the middle nasal vault, placing spreader grafts, and reconstituting the dorsal L-strut, performing septal reconstruction or extracorporeal septoplasty. In this paper, we present our technique of repairing the saddle nose deformity using a "push up" method that preserves the middle vault anatomy and reconstitutes the proper projection of the middle-third of the nose.

Dorsal Augmentation Using Autologous Costal Cartilage or Microfat-Infused Soft Tissue Augmentation.

Costal cartilage grafting is increasing in popularity with increased demand for augmentation rhinoplasty and increased need for grafting material for structure rhinoplasty techniques. Use of costal cartilage for dorsal grafting is both art and science. The art is demonstrated in the act of carving a dorsal graft that will reflect the actual contour of the nasal dorsum. The science is linked to the methodology of how the grafts are contoured to match the patient's desires and how the graft is fixed to the bony dorsum to minimize the risk of warping and displacement. Variations in dorsal graft design and methods of fixation are described. Use of the perichondrial interface between dorsal graft and perforated/rasped nasal dorsum acts to ossify the dorsal graft to the underlying bone, creating an immobile and natural appearing nasal dorsum. The fixation of the dorsal graft limits movement and hence decreases the likelihood of warping or deformity. Use of microfat in rhinoplasty has tremendous potential for camouflage and to promote healing of compromised tissues. Using microfat-infused soft tissue augmentation (MISTA), the surgeon is able to deliver microfat to an open surgical field, promote healing, and provide soft tissue augmentation. In this technique, microfat is injected into soft tissue carriers (perichondrium, temporalis fascia, etc.) and then implanted into the surgical field. MISTA has tremendous potential utility in many areas of cosmetic and reconstructive surgery.

Rhinoplasty of the Aging Nose.

The process of aging leads to countless bodily changes on both a macro- and microscopic scale. No organ system is unaffected; however, the nose is especially susceptible. Sun damage, hormone levels, regenerative capability, tissue elasticity, bone resorption, and the effects of gravity contribute to produce classic signs and symptoms. Rhinoplasty of the aging nose requires a comprehensive understanding of aging facial anatomy combined with surgical techniques designed to resist these ubiquitous remodeling forces over time.

Clinical Use of GalaFLEX in Facial and Breast Cosmetic Plastic Surgery.

Resolution of ptosis is a key step to the success of many plastic surgery procedures. Ptosis is a manifestation of tissue stretch. Tissue stretch can occur as a result of the natural aging process or health of the patient, or tissue may stretch under added weight or volume, such as when implants are placed. Surgical rejuvenation of ptotic tissues is very effective and results in marked changes in the patient profile yet the tissue that resulted in the need for the procedure first place has not improved and ptosis can recur. Recent developments in long-term resorbable porous materials have provided surgeons with the opportunity to experiment with tissue reinforcement in plastic surgery procedures. These new materials have a low profile, rapid tissue integration, and a long-term strength retention profile. Long-term resorbable scaffolds such as poly-4-hydroxybutyrate (P4HB) natural scaffold (GalaFLEX scaffold, Galatea Surgical, Inc., Lexington, MA) have shown promise for a host of plastic surgery indications. This article presents clinical experience with GalaFLEX for soft tissue reinforcement in three different clinical applications; including the reinforcement of the superficial muscular aponeurotic system (SMAS) in minimally invasive facelift, reinforcement of the skin envelope in mastopexy, and reinforcement of the breast capsule (pocket) in revisional breast surgery. Soft tissue reinforcement has been shown to provide increased mechanical strength as well as improved maintenance of postoperative results. LEVEL OF EVIDENCE: 5 Therapeutic.

Structural Approach to Secondary Repair of the Unilateral Cleft Lip Nasal Deformity.

SUMMARY: Management of the unilateral cleft lip nasal deformity is complex because of the underlying significant asymmetry of the lower lateral cartilages and soft tissues of the nasal base. Suturing and grafting techniques may leave the patient with residual asymmetries of the nasal tip and nostrils. Some of this residual asymmetry may be attributable in part to the anchoring effect of the vestibular skin attachments to the lower lateral cartilages. This article discusses the use of lateral crural release, repositioning, and support with lateral crural strut grafts to manage the nasal tip. The technique involves freeing the vestibular skin from the undersurface of the lateral crura and domes and placement of lateral crural strut grafts with or without amputation of the ipsilateral dome and lateral crura to allow precise resuturing to the caudal septal extension graft. This technique is coupled with the use of a caudal septal extension graft to stabilize the nasal base and provide a strong foundation for the repair. Treatment of the nasal base may require skeletal augmentation to aid in creating symmetry of the alar insertions. Costal cartilage is needed in most cases to provide adequate structural support. Nuances in technique are discussed to help maximize outcomes.

Subtotal septal reconstruction: an update.

Subtotal septal reconstruction is a surgical technique used to reconstruct severe septal deviations that are not easily repaired using less invasive methods. Patients with identifiable septal fractures across the caudal or dorsal segments of the L-strut are good candidates. These patients may present with deformities such as the deviated nose or saddle nose. Adequate autologous cartilage is needed to reconstruct the septum. The deviated segments of the nasal septum are removed and then reconstructed by replacing the caudal septum with a straight piece of septal cartilage fixated to the nasal spine. The bilateral extended spreader grafts fixated to the remnant dorsal strut is then fixed to the caudal septal replacement graft to reconstitute the L-strut. In some cases, the dorsal strut may overlap the caudal portion of the L-strut to complete the repair. Care must be taken in setting nasal length, projection, rotation, and supratip break. If these parameters are not set very carefully deformity may ensue. Other potential complications include change in the upper lip smile or a crease forming in the upper lip when the patient smiles. This is a complex technique and must be performed with special care to avoid deformity.