Transection of Pitanguy's Midline Ligament to Avoid Supratip Depression in Closed-Approach, Low-Septal-Resection Dorsal Preservation Rhinoplasty.

BACKGROUND: Supratip depression is a common complication after preservation rhinoplasty. OBJECTIVES: This aim of this paper was to present a simple surgical maneuver to prevent supratip depression. METHODS: Thirty-six patients who underwent closed-approach, low-septal-resection dorsal preservation rhinoplasty between January and June 2021 were included in this retrospective study. Depending on the operation performed on Pitanguy's midline ligament, the patients were divided into 2 groups as follows: (1) a group in which Pitanguy's midline ligament was transected (transection group); and (2) a group in which Pitanguy's midline ligament was preserved (preservation group). Standardized postoperative 6-month lateral-view photographs were scanned for the presence of supratip depression or pollybeak deformity. The Rhinoplasty Outcome Evaluation (ROE) scale was applied at 6 months. RESULTS: Supratip depression was observed in 4 patients in the preservation group (n = 16), but was not observed in any of the patients in the transection group (n = 20; P < 0.05). There was no pollybeak deformity in either group. With respect to the Rhinoplasty Outcome Evaluation scores and number of satisfied patients, no statistically significant difference was found between the transection and preservation groups (P > 0.05). CONCLUSIONS: Transecting Pitanguy's midline ligament reduces the likelihood of supratip depression and does not affect the likelihood of pollybeak deformity in closed-approach, low-septal-resection dorsal preservation rhinoplasty.

Understanding Approaches to the Dorsal Hump.

Dorsal hump reduction is a central component of western aesthetic rhinoplasty. Surgical success begins with knowledge of aesthetic ideals and accurate preoperative analysis. Knowledge of the patient's distortion from aesthetic ideals informs approach, technique, and instrument selection. Both endonasal and external approaches are suitable for dorsal hump reduction, though the latter affords more versatility when other surgical modifications are necessary. The main techniques consist of en bloc, Skoog, and component resection. Each has their distinct advantage, though a surgeon's comfort level with each should impact technique selection. Completion of the dorsal reduction often leaves a defect that must be reconstructed. Failure to anticipate the potential long-term sequelae and appropriately manage the dorsal defect can lead to a poor result and patient dissatisfaction.

Reconstruction of nasal tip support in primary, open approach septorhinoplasty : A retrospective analysis between the tongue-in-groove technique and the columellar strut.

The reconstruction of the nasal tip support is one of the most essential issues in septorhinoplasty. A comparison of the results after using the tongue-in-groove technique and the columellar strut technique was the target of this study. Thirty-three patients who underwent a primary, open approach septorhinoplasty using the above-mentioned techniques were retrospectively analyzed. The gain in tip rotation postoperatively, the sensitivity and the rigidity of the nasal tip and the aesthetic outcome after surgery were examined and evaluated. Both techniques led to an increase in nasal tip rotation postoperatively. The gain in rotation was higher in patients, treated with the tongue-in-groove technique (p = 0.0052). The sensitivity of the tip region in the tongue-in-groove group of patients was significantly lower than that in the columellar strut group of patients (p = 0.0424). Both techniques led to high percentages of tip rigidity after surgery with satisfactory aesthetic results though. The tongue-in-groove technique and the columellar strut technique are both reliable techniques for reconstructing the nasal tip support and correcting a droopy tip. Although the tongue-in-groove technique might result in a more significant increase in tip rotation, it leads to less sensitivity in the tip region.

Refining the Nasal Dorsum with Free Diced Cartilage.

Refining the nasal dorsum has become a major challenge in modern rhinoplasty as irregularities of the nasal dorsum account for a significant number of revision surgeries. In our department, free diced cartilage is now routinely applied for smoothening of the nasal dorsum. In this retrospective study, the outcomes with regard to irregularities or contour deficits of the nasal dorsum of 431 rhinoplasty cases operated by a single surgeon between July 2013 and June 2015, using free diced cartilage, are compared with 327 cases operated by the same surgeon between January 2007 and December 2008, before the introduction of the free diced cartilage technique. A decrease in early revision surgeries (i.e., revision within the 2-year period evaluated) due to dorsal irregularities or contour deficits is seen. Being a quick, easy, and highly cost-effective procedure, we feel that free diced cartilage is currently the ideal technique for refinements of the nasal dorsum.

Pollybeak Deformity in Middle Eastern Rhinoplasty: Prevention and Treatment.

The pollybeak deformity is one of the commonest causes of revision rhinoplasty. The Middle Eastern nose has certain criteria that predispose to the development of pollybeak deformity. The aim of this study is to detect the factors contributing to the development of pollybeak deformity in the Middle Eastern nose and methods used to prevent as well as to treat such deformity. Out of the 1,160 revision patients included in this study, 720 (62%) patients had a pollybeak deformity. The commonest contributing factors included underprojected tip with poor support in 490 (68%) patients, excessive supratip scarring in 259 (36%) patients, overresected bony dorsum in 202 (28%) patients, and high anterior septal angle in 173 (24%) patients. The methods used by the authors to treat the pollybeak deformity are described, along with the local steroid injection protocol used to guard against the recurrence of pollybeak deformity.

The Articulated Alar Rim Graft: Reengineering the Conventional Alar Rim Graft for Improved Contour and Support.

Surgical refinement of the wide nasal tip is challenging. Achieving an attractive, slender, and functional tip complex without destabilizing the lower nasal sidewall or deforming the contracture-prone alar rim is a formidable task. Excisional refinement techniques that rely upon incremental weakening of wide lower lateral cartilages (LLC) often destabilize the tip complex and distort tip contour. Initial destabilization of the LLC is usually further exacerbated by "shrink-wrap" contracture, which often leads to progressive cephalic retraction of the alar margin. The result is a misshapen tip complex accentuated by a conspicuous and highly objectionable nostril deformity that is often very difficult to treat. The "articulated" alar rim graft (AARG) is a modification of the conventional rim graft that improves treatment of secondary alar rim deformities, including postsurgical alar retraction (PSAR). Unlike the conventional alar rim graft, the AARG is sutured to the underlying tip complex to provide direct stationary support to the alar margin, thereby enhancing graft efficacy. When used in conjunction with a well-designed septal extension graft (SEG) to stabilize the central tip complex, lateral crural tensioning (LCT) to tighten the lower nasal sidewalls and minimize soft-tissue laxity, and lysis of scar adhesions to unfurl the retracted and scarred nasal lining, the AARG can eliminate PSAR in a majority of patients. The AARG is also highly effective for prophylaxis against alar retraction and in the treatment of most other contour abnormalities involving the alar margin. Moreover, the AARG requires comparatively little graft material, and complications are rare. We present a retrospective series of 47 consecutive patients treated with the triad of AARG, SEG, and LCT for prophylaxis and/or treatment of alar rim deformities. Outcomes were favorable in nearly all patients, and no complications were observed. We conclude the AARG is a simple and effective method for avoiding and correcting most alar rim deformities.

Preventing Elevated Radix Deformity in Asian Rhinoplasty with a Chimeric Dorsal-Glabellar Construct.

BACKGROUND: Asian facial aesthetic surgery should enhance, but not change, natural features. Augmentation rhinoplasty is a hallmark of Asian cosmetic surgery. In the authors' experience, I-shaped implants can elevate and efface the radix, leading to an unnatural appearance (elevated radix deformity). OBJECTIVES: The Chimeric technique was developed to control final radix position and preserve the nasal profile. We aim to demonstrate that the Chimeric technique promotes forward projection, not elevation, of the radix. METHODS: Between 2013 and 2015, 49 patients underwent rhinoplasty with I-shaped implants. Nineteen patients had Chimeric dorsal-glabellar implants, 30 did not. Standardized photographs were obtained at every visit. Novel and established photogrammetric parameters were used to describe radix position and position change. A retrospective chart review provided additional procedural details and outcomes data. RESULTS: Patients were followed for 10.8 months (range, 2-36 months). Nasal height increase (113% vs 107%) and bridge length increase (118% vs 105%) were significantly greater when the Chimeric technique was not performed (P < .0001). The nasofrontal angle increased 6° in both groups; there was no difference between groups. The vector of radix position change was 26.1° in the Chimeric group and 63.4° in the traditional group (P < .0001). CONCLUSIONS: The Chimeric technique preserves the nasal profile with a favorable (horizontal) radix transposition vector. There was not a significant difference in final radix position when Chimeric rhinoplasty was performed because that is controlled by implant thickness and position. The technique did not blunt the radix significantly. LEVEL OF EVIDENCE 4: Therapeutic.

Immediate functional and cosmetic open rhinoplasty following acute nasal fractures: our experience with Asian noses.

BACKGROUND: Closed reduction and splinting are generally recommended in the acute management of nasal fractures. Although open reduction is recommended for more severe nasal fractures, immediate functional and cosmetic open rhinoplasty following nasal fractures has not been described for Asian noses. OBJECTIVES: The authors document their experiences with combining open reduction of acute nasal fractures with simultaneous cosmetic correction of preexisting aesthetic concerns in an Asian population. METHODS: Twenty-five Asian patients underwent primary functional and cosmetic open rhinoplasty immediately following acute nasal fracture. Grafts consisted of autologous material, including septum, concha, rib, and deep temporal fascia. Prior to opening the nose, anatomical reduction of the bony vault fractures was performed. Spreader grafts were used to stabilize the fractured or dislocated dorsal septum as well as to straighten the nose. Aesthetic refinement of the nose included lengthening, refining the tip, and increasing tip projection and was performed according to the patients' aesthetic desires. Patient satisfaction was subjectively reported on a 1 to 10 scale. RESULTS: Mean follow-up was 17 months (range, 10-24 months). Twenty-three patients rated the results of their procedures as 7 or higher. Functionally, all patients were breathing as well or better postoperatively compared with their preinjury functional state. One patient (4%) underwent a secondary filler procedure for a slight dorsal irregularity. CONCLUSIONS: Immediate cosmetic and functional open rhinoplasty is safe, predictable, and effective in Asian patients. LEVEL OF EVIDENCE: 4.

Pollybeak deformity: how to avoid, how to cure.

We reviewed the Pollybeak deformity from prevention to treatment in all aspects. Research methods included searching online databases such as Google, Google Scholar, PubMed, and Proquest Central at King Saud University. We used terms like "Pollybeak deformity", "rhinoplasty", "etiology", and "treatment" to find related articles. Pollybeak deformity, an undesirable side effect of rhinoplasty, manifests as a dorsal nasal convexity resembling a parrot's beak. A dorsal hump that develops in the supratip region of the nose "pushes" the tip down, leading to under-rotation. Several factors may be at play here. When a surgeon fails to recognize the aberrant tip-supratip relationship that distinguishes this abnormality during the intraoperative evaluation of the nose, the result is a pollybeak. There is also the risk of pollybeak deformity, which the surgeon might be unable to predict. Supratip scar tissue is more common in people with thick skin and soft tissue envelopes. Medical intervention is only effective for soft-tissue pollybeaks when caught early. Injecting corticosteroids into the supratip dead space can alleviate edema and slow scar tissue formation. Surgical excision of scar tissue from the dorsum of the nose can repair the pollybeak deformity. Surgical correction of a supratip fullness that causes a disparity between the tip and supratip is known as a "pollybeak deformity". The appearance of the nose in some individuals with pollybeak deformity can resemble that of a bird, which can cause them to feel self-conscious and embarrassed. Therefore, treatment with medicine or surgery is required for these ailments.

Lemmo's flap for nasal dorsum reconstruction.

PURPOSE: Reconstruction of nasal defects is an antique challenge for surgeons. The first reported technique is dated 600 B.C. Since then a number of reconstructive options have been proposed in the literature. Some principles, first stated by Buget and Menick must be always taken into account when planning such reconstructions. In detail, every reconstruction should respect the subunit principle and the scars should always be well hidden in the passage between adjacent subunits. The flap proposed in the present paper adheres to the cited principles and leads to optimal nasal dorsum reconstruction in selected cases. MATERIALS AND METHODS: From April 2008 to March 2009, 5 patients were reconstructed with Lemmo's flap after local excision of 3 basal cell carcinomas and 2 squamous cell carcinomas affecting the the skin of the nasal dorsum in its caudal portion. RESULTS: In all cases a pleasing aesthetic result was obtained, no postoperative deformity was observed and all the scars were unnoticeable. CONCLUSIONS: The Lemmo's flap described in the present paper can be considered a valid choice for nasal dorsum skin reconstruction and is preferable over other techniques for reconstruction of small to medium sized defects of the skin of the caudal dorsum.

Nasal tip complications.

As cosmetic nasal surgery becomes increasingly more popular worldwide, postoperative nasal tip deformities have also become far more prevalent. Owing to the cosmetic prominence of the nose and to the functional importance of the nasal airway, postsurgical nasal tip deformities often result in debilitating emotional and physiological consequences. However, contemporary principles of cosmetic and functional nasal surgery, when applied expertly, will typically prevent such complications and will simultaneously permit a natural, attractive, and well-functioning nose. This article explores the mechanisms leading to common iatrogenic deformities of the nasal tip and provides alternative techniques for the safe and effective modification of nasal tip contour.

Rhinoplasty and bony vault complications.

Complications of bony nasal vault surgery can be avoided with a thorough preoperative assessment of the nasal anatomy and meticulous surgical technique. When complications arise, it is imperative to identify the irregularity and undertake the corrective measures. This article highlights possible complications of bony nasal vault surgery and their etiologies, appearances, and management.

Avoiding complications of the middle vault in rhinoplasty.

Functional and aesthetic abnormalities of the middle nasal vault are frequent reasons for seeking revision rhinoplasty. Complications in rhinoplasties are inevitable; understanding their etiology can help reduce their occurrence. We will examine the more common sequelae, likely causes, and predisposing factors as well as strategies for prevention.

Avoiding and correcting complications in perinasal trauma.

Injuries to the nose and perinasal region are common. Although the nasal fractures are commonly recognized and properly addressed, injuries to adjacent structures such as the orbit, medial canthus, and midface skeleton can be missed or misdiagnosed, leading to improper primary treatment and subsequent secondary deformities. In this discussion, three common injuries will be discussed, including nasomaxillary fractures, limited naso-orbital-ethmoid fractures, and severe central facial injuries with naso-orbital-ethmoid fractures. For instructional purposes, a case example of inadequate primary diagnosis and subsequent delayed or secondary management will be followed by a case example of proper initial diagnosis and proper primary management.

Reverse nasal SMAS-perichondrium flap to avoid supratip deformity in rhinoplasty.

BACKGROUND: Supratip deformity is an iatrogenic convexity that occurs cephalically to the nasal tip. This is also known as "parrot beak" deformity and causes an unnatural appearance of the nose. In the literature there are several explanations of the mechanism of the deformity and methods to correct it. One of the most accepted theories about the cause of supratip deformity is overresection of the caudal dorsum. Healing soft tissues fill in the gap created between the septum and the tip of the lower lateral cartilages, leading to fullness in the supratip area. The lower third and basically distal third of the middle third of the nose include several muscle groups, ligamentous structures, and perichondrium as the subcutaneous soft tissues. METHODS: With the idea of elevating a reverse-based flap basically from the lower third and the lower third of the middle third of the nose, including the perichondrium and SMAS tissue, we aimed to reduce this gap, which has the potential to accumulate soft tissues that cause supratip fullness. Between December 2008 and July 2010, the reverse nasal SMAS-perichondrium flap was used in 42 primary rhinoplasty patients. RESULTS: This flap was used in 42 patients. Follow-up ranged from 3 to 18 months. No early or late complications were noted, such as infection, excessive bleeding, or extended edema. Minor revisions were performed in only two patients with the aim of achieving a smoother nasal dorsum. CONCLUSIONS: The reverse nasal SMAS-perichondrium flap is a new flap. The results presented here are not long term; however, the preliminary results are promising. The flap should be avoided in cases of thin skin, or at least be used with caution, whereas in thick skin cases it is very safe. Further studies in larger groups are required to better define the advantages and disadvantages of this flap.

Assessment of nose protector for sport activities: finite element analysis.

There has been a significant increase in the number of facial fractures stemming from sport activities in recent years, with the nasal bone one of the most affected structures. Researchers recommend the use of a nose protector, but there is no standardization regarding the material employed. Clinical experience has demonstrated that a combination of a flexible and rigid layer of ethylene vinyl acetate (EVA) offers both comfort and safety to practitioners of sports. The aim of the present study was the investigation into the stresses generated by the impact of a rigid body on the nasal bone on models with and without an EVA protector. For such, finite element analysis was employed. A craniofacial model was constructed from images obtained through computed tomography. The nose protector was modeled with two layers of EVA (1 mm of rigid EVA over 2 mm of flexible EVA), following the geometry of the soft tissue. Finite element analysis was performed using the LS Dyna program. The bone and rigid EVA were represented as elastic linear material, whereas the soft tissues and flexible EVA were represented as hyperelastic material. The impact from a rigid sphere on the frontal region of the face was simulated with a constant velocity of 20 m s(-1) for 9.1 µs. The model without the protector served as the control. The distribution of maximal stress of the facial bones was recorded. The maximal stress on the nasal bone surpassed the breaking limit of 0.13-0.34 MPa on the model without a protector, while remaining below this limit on the model with the protector. Thus, the nose protector made from both flexible and rigid EVA proved effective at protecting the nasal bones under high-impact conditions.

A prospective study on the effect of modified alar cinch sutures and V-Y closure versus simple closing sutures on nasolabial changes after Le Fort I intrusion and advancement osteotomies.

PURPOSE: The purpose of this study was to determine whether a modified alar cinch suture and V-Y closure (mACVY) have a beneficial effect on labial form after Le Fort I intrusion and advancement osteotomies and whether they result in excessive upward nasal tip rotation. Both are possible effects compared with simple closing sutures (SCS). PATIENTS AND METHODS: A prospective study was carried out on 56 patients, 31 with mACVY and 25 with SCS. Lateral cephalograms taken immediately before and 18 months after operation were used, measuring horizontal and vertical changes of the following landmarks: anterior and posterior nasal spine, A-point, incision superior, pronasale, subnasale, labiale superior, and stomion superior, as well as angular changes of sella-nasion-pronasale, and changes in upper vermilion exposure. Statistical analysis was performed on intragroup, paired t test, and intergroup differences, unpaired t test (P < .05). RESULTS: The horizontal and vertical changes of labiale superior were significantly larger for mACVY versus SCS, and the angle sella-nasion-pronasale increased in mACVY versus SCS. However, no significant difference was found for vertical changes of the nasal tip. Upper vermilion exposure increased with mACVY versus SCS. CONCLUSION: mACVY has a beneficial effect on labial form, and excessive upward rotation of the nasal tip is prevented.

Treatment of nasoethmoid-orbital fractures using Kirschner wire fixation of the nasal septum.

As a postoperative complication in nasoethmoid-orbital fractures, nasal depression often occurs. The cause of this is an overlooked left nasal septum fracture. By reducing and fixing the nasal septum, nasal depression could have been avoided. Kirschner wire is useful for the fixation of the nasal septum, and it is fixed with zygomatic bone or/and frontal process of the maxillary bone. Three cases of nasoethmoid-orbital fractures were treated with this method. Kirschner wire fixation of the nasal septum is a simple and an easy method and can avoid unnecessary bone graft.

Pediatric nasal fractures: evaluation and management.

Nasal fractures have been reported as 1 of the 3 most commonly encountered pediatric facial bone fractures. The most common causes of nasal fractures in this age group are auto accidents (40%), sports injuries (25%), intended injuries (15%), and home injuries (10%). Nasal fractures are usually treated with closed reduction (Higuera S, Lee EI, Stal S. Nasal trauma and the deviated nose. Plast Reconstr Surg 2007;120:64S-75S). This results in a significant incidence of posttraumatic deformities, often requiring secondary surgical treatment. For this reason, it is paramount to pay careful attention to the underlying structural nasal anatomy during the initial diagnosis and management.

A Comprehensive Strategy for Improving Nasal Outcomes After Large Maxillomandibular Advancement for Obstructive Sleep Apnea.

Background: Rate of corrective nasal surgery after maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) has been reported to be 18.7% for functional and aesthetic indications. Objective: Describe a comprehensive strategy to optimize nasal outcomes with MMA for OSA. Methods: A retrospective review of patients undergoing MMA for OSA in a tertiary referral center was performed, with a comprehensive perioperative intervention to optimize nasal outcomes from January 2014 to February 2018. Outcomes included the Apnea-Hypopnea Index (AHI), oxygen saturation (SpO2) nadir, corrective nasal surgery needed after MMA, and Nasal Obstruction Symptom Evaluation (NOSE) scores. Results: AHI after MMA showed significant reduction (-34.65, p < 0.001), SpO2 nadir increased (+6.08, p < 0.001), and NOSE scores decreased (-5.96, p < 0.001). Corrective nasal surgery needed after MMA was reported in 6.5% (8 of 122) subjects at a mean of 8.5 months, ranging from 1 to 24.7 months. Six subjects underwent either septoplasty and/or valve stenosis repair, and two subjects underwent functional and aesthetic rhinoplasty. Conclusion: A perioperative strategy was applied since 2014 that showed effectiveness in reducing post-MMA corrective nasal surgery to 6.5%.