Nasal Lining Repair: A Comprehensive Literature Review.

BACKGROUND: Currently, there are limited reviews in the dermatology literature on how to approach reconstruction of nasal lining in full-thickness nasal defects resulting from Mohs micrographic surgery. Given variable training and experience, dermatologic surgeons may seek additional references to help reconstruct certain advanced defects. We sought to synthesize literature from dermatologic surgery, plastic surgery, and otolaryngology to review repair options and considerations for repair of nasal lining defects. OBJECTIVE: To present a comprehensive literature review of repair options for nasal lining reconstruction and discuss advantages, disadvantages, specific anatomic considerations, and techniques to execute such options. MATERIALS AND METHODS: Articles from several different reconstructive specialties including dermatologic/Mohs surgery, otolaryngology, and plastic and reconstructive surgery were reviewed. Instructive images were compiled to illustrate several techniques, with additional medical illustration recreations included to help showcase important reconstructive approaches. RESULTS: A comprehensive descriptive review of nasal lining repair options for the reconstructive surgeon. CONCLUSION: Advanced tumors can result in full-thickness nasal defects, and this review describes various reconstructive options for reconstruction based on the extent of the defect.

Letter to editor: Exploring the influence of nasal morbidity on quality of life following endoscopic endonasal skull base surgery: a retrospective cohort study of 95 patients.

This retrospective cohort study evaluated the impact of nasal morbidity on quality of life following endoscopic endonasal skull base surgery (EESBS) using the Sino-Nasal Outcome Test-22 (SNOT-22) and Anterior Skull Base Inventory (ASB-12). While 89% of patients found the nasal morbidity acceptable given the surgical goals, limitations include the study's retrospective nature, specific focus on certain pathologies, and a short follow-up period of up to 6 months. Future research should utilize comprehensive outcome assessment tools and consider broader patient populations to enhance study validity and applicability.

Revisiting the Anchor Flap for Nasal Defects: How It Fits in the Current Reconstruction Paradigm.

The anchor or Peng flap, first described in 1987, has not been comprehensively discussed in the literature since 2008. The anchor flap is worth revisiting as a useful advancement-rotation flap for medium-sized defects of the distal nose. More recent variations to the flap design incorporate medial cheek advancement and allow for versatility in its use for wide defects of the nasal tip, supratip, and dorsum. The anchor flap is a suitable reconstructive option for defects for which the bilobed/trilobed flap, dorsal nasal rotation flap, or interpolated flap would be considered. We review various designs of the anchor flap and discuss how it can be considered in the modern reconstructive paradigm.  J Drugs Dermatol. 2024;23(1):1271-1273.     doi:10.36849/JDD.7532.

The Two-Stage Folded Paramedian Forehead Flap Without Cartilage Grafts for Full Thickness Distal Nasal Defects: A Review of 35 Patients.

BACKGROUND: Full thickness defects of the ala, soft triangle, and nasal tip involving the nasal lining have traditionally been repaired with the three-stage folded paramedian forehead flap (FPFF), with a cartilage graft for support. For similar defects, the authors utilize the two-stage FPFF without cartilaginous support which provides reproducible functional and aesthetic results.  Objective: To describe the authors’ experience with the two-stage FPFF, including outcomes, complications, and design modifications to enhance functional and aesthetic success.  Methods: An IRB-approved retrospective database review of FPFF was performed at two sites. Using postoperative photographs, outcomes were assessed by blinded non-investigator dermatologist raters using a modified observer scar assessment scale. RESULTS: Thirty-five patients were reconstructed using the two-stage FPFF without cartilage grafts. Subjective assessment of scar vascularity, pigment, relief, and thickness by 3 independent reviewers yielded an overall cosmesis score of 8.4±1.9 (out of 40). CONCLUSION: The two-stage FPFF without cartilage grafts is a reliable, cosmetically elegant repair that can provide optimal functional and aesthetic results for complex unilateral distal nose defects.J Drugs Dermatol. 2024;23(4): doi:10.36849/JDD.7358.

Endoscopic precaruncular medial transorbital and endonasal multiport approaches to the contralateral skull base: a clinicoanatomical study.

OBJECTIVE: Minimally invasive endoscopic endonasal multiport approaches create additional visualization angles to treat skull base pathologies. The sublabial contralateral transmaxillary (CTM) approach and superior eyelid lateral transorbital approach, frequently used nowadays, have been referred to as the "third port" when used alongside the endoscopic endonasal approach (EEA). The endoscopic precaruncular contralateral medial transorbital (cMTO) corridor, on the other hand, is an underrecognized but unique port that has been used to repair CSF rhinorrhea originating from the lateral sphenoid sinus recess. However, no anatomical feasibility studies or clinical experience exists to assess its benefits and demonstrate its potential role in multiport endoscopic access to the other contralateral skull base areas. In this study, the authors explored the application and potential utility of multiport EEA combined with the endoscopic cMTO approach (EEA/cMTO) to three target areas of the contralateral skull base: lateral recess of sphenoid sinus (LRSS), petrous apex (PA) and petroclival region, and retrocarotid clinoidocavernous space (CCS). METHODS: Ten cadaveric specimens (20 sides) were dissected bilaterally under stereotactic navigation guidance to access contralateral LRSS via EEA/cMTO. The PA and petroclival region and retrocarotid CCS were exposed via EEA alone, EEA/cMTO, and EEA combined with the sublabial CTM approach (EEA/CTM). Qualitative and quantitative assessments, including working distance and visualization angle to the PA, were recorded. Clinical application of EEA/cMTO is demonstrated in a lateral sphenoid sinus CSF leak repair. RESULTS: During the qualitative assessment, multiport EEA/cMTO provides superior visualization from a high vantage point and better instrument maneuverability than multiport EEA/CTM for the PA and retrocarotid CCS, while maintaining a similar lateral trajectory. The cMTO approach has significantly shorter working distances to all three target areas compared with the CTM approach and EEA. The mean distances to the LRSS, PA, and retrocarotid CCS were 50.69 ± 4.28 mm (p < 0.05), 67.11 ± 5.05 mm (p < 0.001), and 50.32 ± 3.6 mm (p < 0.001), respectively. The mean visualization angles to the PA obtained by multiport EEA/cMTO and EEA/CTM were 28.4° ± 3.27° and 24.42° ± 5.02° (p < 0.005), respectively. CONCLUSIONS: Multiport EEA/cMTO to the contralateral LRSS offers the advantage of preserving the pterygopalatine fossa contents and the vidian nerve, which are frequently sacrificed during a transpterygoid approach. This approach also offers superior visualization and better instrument maneuverability compared with EEA/CTM for targeting the petroclival region and retrocarotid CCS.

Marsupialization as an alternative to reconstruction in endoscopic skull base surgery. How I do it.

BACKGROUND: To treat extradural solid-cystic lesions of the ventral skull base, a pedicled nasoseptal flap (NSF) maintains patency of the marsupialized cavity and prevents restenosis and cyst recurrence. METHODS: The authors provide a step-by-step description of the surgical technique valid in different lesions of the skull base, all treated via the endoscopic endonasal approach (EEA). The application is demonstrated by an operative video. CONCLUSION: In selected lesions, endoscopic marsupialization using an NSF ensures drainage and ventilation of the surgical cavity. Re-epithelialization provided by a pedicled flap is a viable alternative to multilayer skull base reconstruction.

Customized ventral bony and dural opening in the transplanum/transtuberculum and transclival variants of extended endoscopic endonasal approach to suprasellar craniopharyngiomas: an approach-based stepwise cadaveric dissection and clinical applicability.

BACKGROUND: Optimal initial exposure through an extended endoscopic endonasal approach (EEA) for suprasellar craniopharyngiomas ensures safe and unrestricted surgical access while avoiding overexposure, which may prolong the procedure and increase neurovascular adverse events. METHOD: Here, the authors outline the surgical nuances of a customized bony and dural opening through the transplanum/transtuberculum and transclival variants of the extended EEA to suprasellar craniopharyngiomas based on the tumor-pituitary stalk relationship. A stepwise cadaveric dissection and intraoperative photographs relevant to the approaches are also provided. CONCLUSION: Safe maximal resection of suprasellar craniopharyngiomas through extended EEAs can be feasibly and safely achieved by implementing of tailored ventral exposure.

Endoscopic endonasal decompression of the optic nerve in the setting of compressive lesions: how I do it.

BACKGROUND: Many lesions in the anterior skull base may compress the optic nerve (ON), leading to vision loss, and even irreversible blindness. Although decompression of the optic nerve has traditionally been achieved transcranially, the endoscopic endonasal approach (EEA) is gaining traction as a minimally invasive approach recently. METHOD: We describe the key steps of an EEA ON decompression. The relevant surgical anatomy with illustration is described. Additionally, a video detailing our technique and instruments on an illustrative case is provided. CONCLUSION: Endoscopic endonasal approach ON decompression with a straight feather blade is a feasible, minimally invasive procedure to decompress the ON in the setting of anterior skull base mass lesions.

Nasal ala V-Y island flap with a superior vascular pedicle based on inferior perforators of the superior alar artery.

For small defects of the anterior nasal ala, a V-Y pedicle advancement flap within the subunit is a useful repair option. Here we propose a modification of this technique, utilising careful dissection to identify inferior perforators of the superior alar artery. Basing this flap on a visualised vascular pedicle aims to prevent common complications of internal mucosal buckling and free margin notching, by allowing more extensive dissection without compromising the vascularity of the flap.

Multi-Subunit Repair With the Nasolabial Burow's Advancement Flap.

AIM: We will describe the use of nasolabial Burow's advancement flaps (perialar crescentic advancements) to repair multi subunit defects of the nasal sidewall including the adjacent cheek, dorsum, tip, and ala without the need of additional flaps. METHODS: This retrospective single centre study analyzed 6 month postoperative photographs using the Manchester Scar scale. The operative technique is described in detail. RESULTS: Of 355 cases, 336 were available for analysis. The median Manchester Scar scale was 7 for both sidewall defects and multi-subunit defects. There were low rates of infection or necrosis. CONCLUSIONS: With the correct technique, the nasolabial Burow's advancement alone is suitable to repair even large multi-subunit defects involving the nasal sidewall, cheek, dorsum, tip, and ala with high-level aesthetic and functional results.

Prevention of nostril lacerations in endonasal drilling procedures by use of a conventional protective ear speculum.

PURPOSE: Injuries of the nasal vestibular skin caused by the rotating burr shafts can represent a tedious complication following endonasal drilling and is experienced sooner or later by every rhino-surgeon. MATERIAL AND METHODS: To protect the nasal entrance from laceration by the free rotating drill shaft we position an otology speculum in the nasal entrance. The speculum is held in place by the scrub nurse during the critical phase of bone drilling. RESULTS: Following the introduction of the ear speculum protection, we successfully treated our dacryocystostamia procedures (n = 27) and median maxillectomia procedures (n = 6) without any further soft tissue erosions. DISCUSSION: Preventive measures for injuries by endonasal drilling procedures are not reported extensively in literature. This stands in contrast to the fact that these injuries are prone to cause significant suffering as amply described in the case of nostril laceration due to nasogastric intubation or nasogastric feeding tubes. CONCLUSION: The use of a readily available, reusable ear speculum in endonasal drill application eliminated the complication of nasal entrance lacerations throughout our institution, hitherto.

Versatile vertical alar resection technique for positioning of the nasal tip.

BACKGROUND: In rhinoplasty, it is very important to adjust the rotation and projection of the tip together harmoniously with the nasal dorsum and face to achieve pleasing results. OBJECTIVE: In this study, our aim is to describe a new modification of the vertical alar resection technique that can effectively regulate nasal tip projection and rotation. MATERIALS AND METHODS: Versatile vertical alar resection (V-VAR) technique was applied to 14 primary and 9 revision rhinoplasty cases with highly projected nasal tip. V-VAR technique consists of three steps. In the first step, the original dome point was marked. In patients with high tip projection and caudal rotation, resection was performed from the lateral crus of the original dome. In patients with high tip projection and cephalic rotation, resection was performed from the medial crus of the original dome. In patients with high nasal tip projection but adequate rotation, an equal amount of resections were performed from both the medial crus and lateral crus of the original dome. The patients were followed in average 18 months (between 12 and 24 months). RESULTS: The desired type of rotation and projection was achieved utilizing V-VAR technique in all patients. All patients had satisfactory esthetic results. CONCLUSIONS: In highly projected nasal tips, the height can be reduced using the proposed V-VAR technique. Rotation in the nasal tip region was maintained, increased or decreased in accordance with the esthetic aims.

Deformity, etiology, solution, sequence (DESS): Facial analysis in rhinoplasty.

PURPOSE: Rhinoplasty is amongst the most challenging surgeries to perfect and can take decades. This process begins during residency; however, residents often have limited exposure to rhinoplasty during their training and lack a standardized method for systematically analyzing and formulating a surgical plan. The DESS (Deformity, Etiology, Solution, Sequence) is a novel educational format for residents that serves to increase their pre-operative comfort with the surgical evaluation and intraoperative planning for a rhinoplasty. MATERIALS AND METHODS: A qualitative study performed at a tertiary academic institution with an otolaryngology residency program evaluating three consecutive residency classes comprised of four residents per class. A 9-item questionnaire was distributed to measure change in resident comfort after utilizing the DESS during their facial plastics rotation. Questionnaire responses highlighted resident comfort with facial nasal analysis, identifying deformities, suggesting surgical maneuvers, and synthesizing a comprehensive surgical plan. RESULTS: Ten of the twelve residents surveyed responded. Of those that responded, comfort in facial nasal analysis, identification of common nasal deformities, surgical planning, and development of an overall surgical plan were significantly improved after completion of the facial plastic rotation. These residents largely attributed their success to the systematic educational format, with an average score of 4.8/5.0 (SD 0.42). CONCLUSION: While rhinoplasty is a challenging artform to master, systematic approaches to analysis and operative planning are vital for teaching and guiding residents. Through this novel methodology, residents display significant improvement in their comfort with facial nasal analysis and overall surgical preparation.

Cog graft, a new septal extension graft for designing nasal tip rotation and projection in rhinoplasty.

BACKGROUND: Adjusting the nasal tip rotation and tip projection according to the patient's face and wishes is a very important stage in rhinoplasty with the use of a cog graft positioning the tip point in the appropriate place is possible by adjusting the nose length, tip projection and tip rotation together. OBJECTIVE: The aim of this study is to facilitate positioning the tip rotation and projection in the appropriate place according to the patient's needs in rhinoplasty with Cog graft. MATERIALS AND METHODS: Cog graft was applied in 32 patients who underwent rhinoplasty. Cog graft was prepared from costal cartilage in 10 patients and from septal cartilage in 22 patients. Cog graft was prepared by shaping the superior edge of the septal extension graft like a gear wheel. It is fixed to provide desired projection to the caudal septum. In the position where rotation and projection are evaluated adequately, the graft is fixed with sutures. They were followed in average 18 months (between 6 and 24 months). RESULTS: Twenty of the patients were primary cases and 12 were revision cases. The targeted rotation and projection results were achieved in all patients. All patients had satisfactory esthetic results. CONCLUSIONS: Cog graft is a useful graft with which we can adjust the nose length, projection and rotation appropriately and in a short time with a single graft.

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.

Internal suspension sutures in tip rhinoplasty.

BACKGROUND: Achieving an aesthetically pleasant tip rotation is paramount in rhinoplasty, and these results should be long-lasting. However, even powerful structural techniques such as septal extension grafts can lose rotation over time, as most support depends on the attachment of the graft to the septal cartilage. METHODS: We describe a simple suture technique to strengthen tip support in rhinoplasty, by suspending it to the cartilaginous dorsum, providing additional support to the tip against forces, such as gravity, scar contraction and muscle tension. CONCLUSIONS: Combining traditional techniques with suspension sutures can improve intraoperative results and could enhance long-term tip stability.

A randomized prospective comparative study on sinonasal morbidity and quality of life of transsphenoidal endoscopic surgery for pituitary adenomas: endonasal versus trans-septal approach.

PURPOSE: Endoscopic endonasal transsphenoidal approach (Endonasal approach) is commonly used to treat pituitary adenomas. The extent of dissection possibly changes the anatomy and the physiology of the nasal cavities and could give rise to post-operative morbidity and the quality of life (QoL). The purpose of this study was to investigate sinonasal morbidity and general QoL in patients who underwent surgery for treatment of pituitary adenoma, comparing Endonasal and endoscopic trans-septal transsphenoidal approach (Trans-septal approach). METHODS: A prospective observational study, recruiting 40 patients undergoing surgery for pituitary adenoma, 20 via Endonasal approach and 20 via Trans-septal approach at our institution. Surveys with Sinonasal Outcome Test-22 (SNOT-22), Chronic Sinusitis Survey (CSS), and Short Form Health Survey 36 version 2 (SF-36v2) were obtained to collect QoL data pre- and postoperatively. RESULTS: All the 40 patients completed the questionnaires. At 6 months postoperatively, the SNOT-22 and CSS score shows significant improvements both in Endonasal approach (p = 0.01) and in Trans-septal approach (p = 0.02). No significant difference in sinonasal morbidity is observed between the two groups for SNOT-22 (p = 0.13) and CSS scores, except for sinus headache (p = 0.49), with a better score in Endonasal approach. The mean SF-36v2 scores remain the same in pre- and post-operative periods, but an improvement in time is seen in general health (p = 0.027), and general health compared to one year ago (p < 0.001). CONCLUSIONS: Endoscopic transsphenoidal surgery has negligible morbidity and does not negatively affect the nasal function in the long term. Endonasal approach and Trans-septal approach are comparable in terms of morbidity outcomes and general QoL, leaving the choice of the approach to the surgeon preference.

The effect of subperichondrial dissection on nasal vascularity in septorhinoplasty operations.

PURPOSE: Nasal vascularization runs above the superficial musculoaponeurotic system (SMAS). Perichondrium covers the lower and upper lateral cartilages. In this study, nasal vascularization was compared between subperichondrial and supraperichondrial dissection in closed septorhinoplasty. METHODS: 95 patients and 41 volunteers were included in this study. Supraperichondrial dissection was performed in 48 patients and subperichondrial dissection was performed in 47 patients. To measure blood stream, laser doppler flowmetry (LDF) was used and measurements were done preoperatively, on the postoperative first week; 3rd month and first year. RESULTS: The nasal tip and dorsum measurements were similar between the preoperative and postoperative first year in both groups (p = 1.000). However, in the supraperichondrial dissection group, nasal tip measurements showed a significant increase between the preoperative and third postoperative months (p = 0.011). This increase was accompanied by an increase in the minimal blood stream (p = 0.014). CONCLUSION: Both subperichondrial and supraperichondrial dissection techniques are physiological and result in fewer complications with minimal permanent vascular damage. We believe incision plays a critical role but keeping the perichondrium intact is important for short-term angiogenesis, where long-term results showed no difference in vascularization.

Nasal axis lateralization suture technique in crooked nose.

PURPOSE: The aim of the present study was to objectively and subjectively compare the preoperative and postoperative aesthetic and functional outcomes of the correction of crooked noses using a suture technique we call "nasal axis lateralization suture (NALS)". METHOD: A total of 36 patients who had preoperative and postoperative photographs taken and who completed the Rhinoplasty Outcome Evaluation (ROE) questionnaire were included in the study. RESULTS: Crooked noses were divided into two groups: C-shaped (17 patients) and I-shaped (19 patients). The preoperative and postoperative nasal axis angles were 145.3 ± 11.9 and 178.5 ± 3.3, respectively, in C-shaped nasal deviation. In I-shaped nasal deviation, on the other hand, the preoperative nasal axis angle was 8.8 ± 2.8, while the postoperative nasal axis angle was 1.4 ± 2.4. In terms of the ideal axis percentage before and after surgery, a significant difference was found between the C-shaped and I-shaped nasal deviation patient groups (p < 0.05). While there was a significant improvement in both groups in the evaluation based on the ROE questionnaire, satisfaction was much higher in the C-shaped nasal deviation group. In both groups, the ROE values of functional and aesthetic outcomes were significantly different compared to the preoperative values of both groups (p < 0.005). CONCLUSION: NALS can be used as an alternative technique to correct both I-shaped and C-shaped nasal axis deviations.

The Use of a Unilateral Curved Spreader Graft in the Management of Crooked Nose Deformity.

AIM OF WORK: The aim of this study is to present a new technique of using spreader grafts in the correction of crooked nose deformity with C-shaped deviation of the middle third of the nose. PATIENTS AND METHODS: This is a prospective case series study conducted on 18 patients with crooked nose deformity with C-shaped deviation of the middle third of the nose. All of the patients were managed by open septorhinoplasty. During surgery, a curved spreader graft was harvested from the nasal septum and placed on the convex side of the C-shaped deviation of the dorsal part of the nasal septum. Objective measurements of the angles of external nasal deviation (END) and the internal nasal valve (INV) angles were performed before and 6 months after the surgery. Subjective assessment of aesthetic satisfaction by the visual analog scale and nasal function by the nasal obstruction symptom evaluation scale was also performed before and 6 months after surgery. RESULTS: Eighteen patients were enrolled in the study and completed the minimum follow-up period of 6 months. The mean follow-up period was 17.3 months. Objectively, there was highly significant ( P < 0.00001) improvement of the END angle and INV angle. Subjectively, there was also highly significant ( P < 0.00001) improvement of both the nasal obstruction symptom evaluation score and the visual analog scale score for aesthetic satisfaction. CONCLUSIONS: The insertion of a curved unilateral spreader graft over the convexity of the deviated nasal dorsum can correct the END, improve the collapsed INV on both sides, and consequently achieve satisfactory aesthetic and functional outcomes.