Application of a Novel Versatile Mini Posterior Nasoseptal Graft in Endoscopic Transsphenoidal Pituitary Adenoma Surgery.

BACKGROUND: Skull base reconstruction is a key technique in patients undergoing endoscopic transnasal skull base surgery. Although a pedicled nasoseptal flap (PNSF) is often used to repair large skull base defects with high-flow cerebrospinal fluid leakage, bone exposure of the donor site of the PNSF can result in long-term crusting. OBJECTIVE: To design a novel and versatile mini posterior nasoseptal graft for the reconstruction of defects in the sellar floor or PNSF or pedicled nasoseptal rescue flap (PNSRF) donor site in patients undergoing pituitary adenoma surgery. METHODS: Patients who underwent pituitary adenoma removal through an endoscopic endonasal approach and repair of a sellar defect or PNSF/PNSRF donor site using the mini posterior nasoseptal graft technique from January 2019 to January 2020 were retrospectively evaluated. Pituitary adenomas were removed using a binostril 4-hand technique through a transnasal transsphenoidal transsellar approach or an expanded transsellar approach. RESULTS: Mini posterior nasoseptal grafts were successfully used in 70 patients who underwent pituitary adenoma removal through an endoscopic transsphenoidal sellar approach. Mini posterior nasoseptal grafts repaired sellar defects in 40 patients and donor site defects of the contralateral PNSF/PNSRF in 30 patients. None of these patients experienced cerebrospinal fluid leakage or major complications. CONCLUSIONS: A mini posterior nasoseptal graft is a safe and effective technique for repairing sellar defects after endoscopic transnasal pituitary adenoma surgery. This technique can also be used to repair defects in PNSF/PNSRF donor sites.

Septal Extension Grafts in Rabbit Models: A Comparative Study Between Costal and Conchal Cartilage Grafts.

BACKGROUND: The septal extension graft (SEG) has become the preferred augmentation rhinoplasty technique for Asian people due to its superiority in correcting tip projection and rotation. OBJECTIVES: The aim of this study was to build a rabbit model for SEG surgery and to compare the postoperative stability of nasal tip support provided by bilateral batten costal and conchal cartilage extension grafts. METHODS: Twenty rabbits underwent SEG surgery with either bilateral batten costal cartilage graft (Group A) or bilateral batten conchal cartilage graft (Group B). Serial photographs were obtained to evaluate the change of the nasal tip shape and graft shape. The observed indices include tip projection, tip angle, shape of extension graft, and histologic features of the extension graft. RESULTS: Twelve weeks after the operation, 1 costal extension graft in Group A (1/10) and 3 conchal extension grafts in Group B (3/10) were reabsorbed. The costal cartilage graft showed better exterior results than conchal cartilage graft in terms of tip projection and angle relapse rate (13.01% vs 25.02% and 15.18% vs 28.73%; P < .05). The costal cartilage graft maintained its structure better than the conchal cartilage graft. A greater degree of calcification and more fibrous capsules around the extension graft were found in Group A. CONCLUSIONS: A rhinoplasty rabbit model was established to compare costal and conchal autologous cartilages for SEG. This model may serve as a training tool for rhinoplasty surgeons. The costal cartilage extension graft is more reliable in terms of stability and should be given more attention.

A Novel Technique for Autologous Supratip Augmentation: Septal Gap Graft.

BACKGROUND: Although it has been common to use artificial implant to augment nasal dorsum in Asian rhinoplasty, the demand for not using it is increasing due to the long-term complications of implants. However, if only the tip is raised without raising the dorsum with implant, it is difficult to avoid supratip depression, so it is difficult to obtain good cosmetic results. The authors would like to report good results, performing an augmentation rhinoplasty that raises the supratip area using the nasal septal cartilage without using an implant. METHODS: Septal gap graft was used in 22 patients undergoing nasal tip surgery from January 2019 to April 2021. Septal gap graft refers to a graft that increases the height of the supratip area by using septal cartilage. Firstly, the authors perform a septal extension graft using the septal cartilage, then the authors fix the lower lateral cartilage in an ideal position, and lastly the authors heighten the nasal tip with onlay graft. The height difference between the nasal bone and the nasal tip, is solved by placing the septal cartilage. Before, during and after surgery, photometric analysis was done by taking clinical pictures. RESULTS: Through the septal gap graft, the supratip depression index was decreased and the nasal tip projection was increased. It was confirmed that the septal gap graft was well maintained at long-term follow-up, and the patients' postoperative satisfaction was also high. CONCLUSIONS: The authors presented a new technique for augmentation rhinoplasty in Asians. Septal gap graft can be used safely and effectively to raise supratip area without using implant.

One-Stage Repair of Alveolar Cleft and Nasal Deformities Using Grafts From Nasal Septum: Application of Vomer, Ethmoid, and Septal Cartilage.

BACKGROUND: Patients with alveolar cleft unrepaired suffer from nasal deformities of different magnitude. Bone and cartilage grafts are harvested through several incisions. In this study, we present a method to simultaneously correct nasal deformities and repair alveolar cleft using grafts from the nasal septum. PATIENTS AND METHODS: All 6 patients with unilateral cleft lip and palate have alveolar cleft unrepaired combined with nasal deformity. Computed tomography scans and 3-dimensional-printed models of vomer and ethmoid bone were used for the purpose of preoperative design and for assessing the magnitude of deformity. Grafts of bone and cartilage from deviated septum were harvested by septoplasty through which dorsum deviation was corrected. Bone grafts from vomer and ethmoid were then fixed to the prepared alveolar cleft to repair the defect and elevate the alar base. Septal cartilage was adjusted into different shapes of grafts and deformities of nasal tip, nostrils, and columella were then corrected by rhinoplasty to restore the symmetry of the nose. RESULTS: Symmetry of nostrils was improved. The height of alar base on the cleft side was elevated to the level close to the noncleft side. Deviation of the septum, nasal dorsum, and columella was corrected. Projection of the nasal tip was adjusted to facial midline. Midface aesthetics was generally improved. CONCLUSION: Application of septal grafts reduce the number of incisions. One-stage repair of alveolar cleft and nasal deformities, with the aid of digital design, improves the postoperative experience and the general outcome of the surgery.

Application of septal extension grafts with auricular cartilage in rhinoplasty. / 耳廓软骨鼻中隔延伸支架移植物在鼻整形术中的应用.

OBJECTIVES: Rhinoplasty is one of the most common cosmetic surgeries in China. Septal extension grafts (SEG) have been widely used in rhinoplasty, but there are few reports on SEG derived from ear cartilage. This study aims to explore the effectiveness and stability of auricular cartilage nasal SEG transplantation in Chinese rhinoplasty. METHODS: A retrospective analysis of 35 rhinoplasty patients admitted from September 2019 to March 2022 has been conducted. Among them, 29 patients underwent rhinoplasty for the first time and 6 patients underwent rhinoplasty with the age of 18-32 (average 22.4) years old. The postoperative follow-up was 3-28 (average 18.5) months. The improvement of the nose shape was observed. The changes of the nose tip angle, nasolabial angle, and nasofrontal angle were compared between before and after the operation, and the complications were recorded. RESULTS: All patients who underwent rhinoplasty with a septal extension grafts constructed from the concha cavity and concha cartilage showed significant improvement in nasal contour. The preoperative nasal tip angle, nasolabial angle, and nasofrontal angle were significantly improved compared with 3 months after operation (all P<0.001), and there was no significant difference between 3 months and 14 months after operation (all P>0.05). The appearance of nasal cavity was satisfactory in 32 patients after operation. Columella deviation occurred in 2 patients and 1 patient complained of downward rotation of the nasal tip, which was satisfied after readjustment of the graft. CONCLUSIONS: The simplified SEG derived from auricular cartilage can provide stable support for the nasal tip, the nasal shape is natural after operation, and minimal trauma of unilateral auricle cartilage transplantation remains.

Prior smoking and nasoseptal flap usage adversely impact quality of life and healing after endoscopic pituitary surgery.

OBJECTIVE: Endoscopic pituitary surgery (EPS) via the endonasal transsphenoidal approach is well established as an effective treatment modality for sellar masses. The objective of this study was to determine the relationship between key patient and operative variables and rhinological outcomes as determined by the 22-item Sino-Nasal Outcome Test (SNOT-22) and endoscopic scores following EPS. METHODS: Prospectively collected SNOT-22 scores and objective endoscopic data were analyzed from a cohort of 109 patients who underwent EPS and had at least 90 days of postoperative follow-up. Trends in postoperative SNOT-22 scores were analyzed using linear mixed-effects models. Time to return to baseline endoscopic score was analyzed using Cox regression. RESULTS: After adjusting for age and sex, the authors found that prior smokers had higher total and rhinological subdomain SNOT-22 scores (p < 0.01, 95% CI 5.82-16.39; p = 0.01, 95% CI 1.38-5.09, respectively) following EPS. Nasoseptal flap use also showed higher total and rhinological subdomain SNOT-22 scores (p = 0.01, 95% CI 1.62-12.60; p = 0.02, 95% CI 0.42-4.30, respectively). Prior sinonasal surgery and concurrent septoplasty did not affect the change in SNOT-22 total scores over time (p = 0.08, 95% CI -0.40 to 0.02; p = 0.33, 95% CI -0.09 to 0.29). CONCLUSIONS: The findings suggest that the evolution of healing and patient-reported quality of life (QOL) measures are multifaceted with contributions from two key variables. Nasoseptal flap usage and prior smoking status may adversely impact postoperative QOL. No variables were found to be associated with objective postoperative endoscopic findings.

The reconstruction of skull base defects in infants using pedicled nasoseptal flap-a review of four cases.

INTRODUCTION: Benign lesions of the skull base are common in the paediatric population, and are usually congenital in aetiology. Majority of these lesions are treated transcranially exposing the patients to a number of risks. Although endoscopic endonasal surgery (EES) helps avoid many of these potential morbidities, CSF leak with its attendant complication remains a big concern. This study reports the use of the Hadad flap in the reconstruction of skull base defects in infants to prevent this problem. The study was conducted on four infants with a mean age of 7 months, who underwent repairs for CSF leaks associated with congenital lesions like meningocele or meningoencephalocele, using the Hadad flap. Of the four patients, three cases were revision cases and one was primary where the patients presented with complaints such as nasal obstruction and watery nasal discharge. Post surgery, the infants were monitored for a mean period of 23 months and no major complications or recurrent CSF drainage were observed. Minor complications that were observed include vestibulitis and crusting in the nose. The utility of the Hadad flap in the reconstruction of skull base defects in the paediatric age group has been controversial while its utility in infants has not been studied in literature so far. We report here in our series four infant patients in whom we believe that the nasal septum and the skull base will develop proportionally to each other, hence lowering the chances of a short flap and eliminating the occurrence of future complications. CONCLUSION: The nasoseptal flap is an effective and safe technique for reconstructing skull base defects in infancy. It can be concluded that this technique does not have any potential effect on septal or craniofacial growth as the flap is harvested only on one side with normal mucosal cover on the other side. There is no posterior septectomy or any form of bony or cartilaginous resection that is performed, hence avoiding any effects on bony growth. No studies have been published in literature so far and to the best of our knowledge, this is the first report describing the efficacy of the nasoseptal flap in infants.

Alar Rim Reconstruction With Autologous Graft Cartilage: External Approach.

Alar deformities are frequently sequels of the incorrect primary rhinoplasties. Malpositions and irregular cartilage as consequence of either inadequated or exaggerated resection are the skeletal representation not only of aesthetic deformities but also collapse or depression, airway obstruction, valve narrowing by scarring, etc. Replace of alar cartilage is mandatory and many techniques have been described using autogenous cartilage graft since either ear or costal areas. Basically, a pocket must be made inside the thickness of ala permitting the placement of the graft. In our experience the placement of the graft was made by an incision in the fold in the base of the ala and a wide and net alar undermining, carving a pocket was carried out until the tip by means of sharp dissection with the scalpel, permitting the placement of the graft "like a sandwich." The reason for this publication is to describe a surgical technique that permits an exact and correct placement of the graft obtaining the recuperation of normal shape, form projection, and functionality of the ala. The external alar incision is conspicuous and it remains hiding inside natural fold in the alar base.

A New Technique for Augmentation Rhinoplasty Using Hybrid Autologous Grafts with Septal Extension Grafts in Asian Patients.

Augmentation rhinoplasty is commonly performed to raise the nasal dorsum in Asian individuals. However, materials used for dorsal augmentation are associated with various surgical challenges and complications. In this article, the authors present a novel dorsal augmentation technique combining hybrid autologous costal grafts with septal extension grafts. The records of 28 patients (19 women and 9 men; mean age: 27 years; range: 18-43 years) who underwent augmentation rhinoplasty (primary or revision) with our novel technique from December 2007 to December 2016 were retrospectively reviewed. Our technique included septal extension grafts for nasal tip projection and hybrid costal cartilage grafts, with a solid boat-shaped portion for bony dorsum augmentation and a fascia-wrapped diced cartilage graft for cartilaginous dorsum augmentation. Objective and subjective outcomes and complications were evaluated. Anthropometric parameters were measured on facial photographs to evaluate surgical outcomes in the 15 primary cases. Objective anthropometric measurements revealed successful augmentation of all nasal parameters. The nasal tip was mobile and comfortable in all patients. Among the 28 patients, 12 (42.9%) were very satisfied, 10 (35.7%) were satisfied, and 6 (21.4%) were unsatisfied with surgical results and required revision surgery. No immediate postoperative complications occurred. Ten (35.7%) patients experienced graft-related complications, including visibility or warping of the solid graft, supratip depression, and caudal deviation of the septal extension graft. None of these complications was serious. Augmentation rhinoplasty using hybrid autologous costal grafts with septal extension grafts allows dorsal augmentation with suitable graft material for each recipient site and can achieve successful outcomes in Asian patients.

Use of Bone-Cartilaginous Unit in Revision Rhinoplasty.

BACKGROUND: Insufficient septal cartilage is a common finding when performing revision rhinoplasty. Such cases require costal or conchal cartilage to be harvested, which is time consuming and brings the risk of morbidity. A new technique involves the use of a septal bone-cartilage composite graft or a bone-cartilaginous (BC) unit as a rhinoplasty graft. OBJECTIVES: The aim of this research was to evaluate the subjective and objective effects of using a BC unit graft in revision rhinoplasty. METHODS: In this clinical trial, we examined 40 patients with insufficient septal cartilage for grafting who were referred to a tertiary center and a private setting from January 2016 to March 2017 for revision septorhinoplasty. The patients had nasal deformity and nasal obstruction. Assessment of surgical outcome was based on anthropometric measurements and by measuring the width of the middle nasal third from photographs, and on 2 patient questionnaires: the Nasal Obstruction and Septoplasty Effectiveness (NOSE) and the Rhinoplasty Outcome Evaluation (ROE) questionnaires. RESULTS: Nasolabial angles and the middle nasal third improved significantly after surgery (P < 0.005). Based on the NOSE questionnaire, 85% of patients had no or mild nasal obstruction, and the ROE questionnaire indicated that 62.5% were completely or very satisfied with the appearance of their nose. CONCLUSIONS: The BC unit is an effective graft in revision rhinoplasty, and can be used in place of the rib graft. In skilled hands, harvesting of this graft results in no morbidity and is not time consuming.

Repair of bony lateral skull base defects equal to or larger than 10 mm by extracorporeally sewed unit-sandwich graft.

OBJECTIVE: To see effectiveness of the senior author's repair technique for repair of large (equal to or larger than 10 mm) bony lateral skull base defects. STUDY DESIGN: Retrospective. SETTINGS: Secondary/tertiary care center. METHODS: We performed retrospective review of 9 surgeries done in our institution between January 2010 and December 2013 for repair of large lateral bony skull base defects. We defined skull base defects extra-cranially and repaired them intra-cranially. We made an extracorporeal sandwich of autologous fascia-bone-fascia (fascia lata and nasal septal bone) and sewed it together to make it into a unit-sandwich graft. This extracorporeally sewed unit-sandwich graft was then inserted to close the large skull base defects either via (1) a cranial slit-window, or (2) the skull base defect itself. Since skull base is bony, bony repair is preferred. Bone plates that are easily available for skull base repair are calvarial and nasal septal bone. Occasionally, harvest of split calvarial bone carries risk of major complications. We preferred nasal septal bone. Harvesting of septal bone even in children using a posterior incision should not disturb the cartilage growth centers. RESULTS: All nine patients were operated by this technique. We had four patients with cerebrospinal fluid leak, and five patients with brain herniation. All these patients had complete reversal of herniation of cranial contents and cessation of cerebrospinal fluid leak. On imaging, in 6 cases the bone graft remained in original intended position after 12 months of surgery. The bone graft was not identifiable in 3 cases. CONCLUSION: The senior author's technique using autologous multi-layered graft is simple to master, repeatable and very effective.

A Stratified Algorithm for Skull Base Reconstruction With Endoscopic Endonasal Approach.

The authors presented our institutional experience with skull base reconstruction techniques and developed a stratified algorithm for different causes of cerebrospinal fluid (CSF) leak. This is a retrospective review of patients who were diagnosed as CSF leak treated with skull base reconstruction or who underwent endoscopic transsphenoidal surgery for sellar and parasellar lesions at our department from August 2012 to April 2017. The authors totally identified 57 (59 operations in total) patients who were divided into 3 groups according to the causes of CSF leak and different reconstruction techniques. All patients underwent skull base reconstruction with specific focus on diagnosis, reconstruction techniques and strategies, and clinical outcome. The reconstruction technique we adopted was the classical multiple-layer technique, as known as "sandwich" technique, with combination of fat tissue, septal bone, autologous fascia lata, artificial dura, and nasoseptal flap (NSF). The NSF was selectively harvested for large defects according to our protocol. The reconstruction failure rate is 4.4% (2 of 45) in patients underwent endoscopic surgery for sellar and parasellar lesions. Reconstruction for postoperative iatrogenic, traumatic, and spontaneous CSF leak achieved 100% success rate; 54.2% (32 of 59) operations were done with "sandwich" plus NSF. The overall failure rate of all reconstructions was 3.4% (2 of 59). A stratified approach with multiple-layer technique and NSF is reliable for skull base reconstruction.

Improvement of Aesthetic and Nasal Airway in Patients With Cleft Lip Nasal Deformities: Rhinoplasty With Septal Cartilage Graft and Septoplasty.

OBJECTIVE: To assess the improvement of nasal morphologies and ventilation after septal cartilage graft and septoplasty of patients with unilateral cleft lip and palate (UCLP). DESIGN: Retrospective case-control study. SETTING: Tertiary stomatology hospital. PATIENTS: In total, 118 patients with UCLP who had been diagnosed with a secondary nasal deformity and had reconstructive rhinoplasty and/or septoplasty between 2010 and 2015. MAIN OUTCOME MEASURES: Nasal Obstruction Symptoms Evaluation (NOSE) questionnaire, septum deviated angle, rhinoplasty satisfaction questionnaire, and 3-dimensional photographs. RESULTS: Average follow-up period was approximately 12 months for both groups. NOSE and 3-dimensional computed tomography (3DCT) analysis demonstrated postoperative improvement in nasal airway function of those patients who underwent rhinoplasty and septoplasty simultaneously ( P < .05). Subjective assessment by patients' visual analog scale (VAS) and objective assessment by 3-dimensional stereophotography demonstrated postoperative improvement in nasal morphologies, particularly the columella deviation angle and nasal depth (representing nasal tip height), which are crucial parameters of nasal aesthetics ( P < .05). CONCLUSIONS: In patients who underwent simultaneous rhinoplasty and septoplasty, nasal symmetry and ventilation function were significantly improved compared to the control group. Septum grafts could provide nasal tip support for patients with cleft lip. Three-dimensional stereophotogrammetry helped us to better visualize the surgical results. Although the septal cartilage of Asian patients is sometimes insufficient for simultaneous use for multiple grafts, septum grafts in rhinoplasty of patients with cleft lip nasal deformities could give support for nasal tips.

Modified Direct-Type Septal Extension Grafts: Their Stability and Usefulness in Asian Rhinoplasty.

BACKGROUND: In Asian rhinoplasty, many autogenous cartilage grafts are required for correction of the nasal tip and columella, but the amount has limitations. A modified direct-type septal extension graft, in continuity with the entire caudal border of the septal cartilage with an edge-to-edge coaptation, can effectively and concomitantly correct the nasal tip and columella deformities using a limited amount of septal cartilage graft. The purpose of this study was to evaluate long-term cosmetic outcomes and stability from the modified direct extension grafts. METHODS: Fifty-seven patients with a follow-up of more than 1 year were enrolled in the study. A total of 11 measurement items were evaluated from basal and right lateral views by photogrammetry using standardized clinical photographic techniques. RESULTS: The overall mean follow-up period was 20.4 months. When comparing the preoperative and postoperative values, the nasal tip projection, nasal bridge length, nasal tip angle, height of nose, and the columellar labial angle increased significantly; additionally, the soft nose width index, width between ac-ac index, nostril axis inclination, columellar length (Rt-Lt), and the alar length (Rt-Lt) decreased significantly. No resorption, buckling, or displacement of the graft was observed during the follow-up period. CONCLUSIONS: The modified direct extension graft demonstrated a marked aesthetic improvement in the nasal tip and columella, and it provided long-term stability. Therefore, the modified direct extension graft is useful for correction of the nasal tip and columella in Asian rhinoplasty.

A New Approach to Upper Eyelid Reconstruction.

BACKGROUND: Reconstruction of large defects of the upper eyelid is challenging because of its complex anatomy and specialized function. The aim of this work is to develop a single-stage reconstruction procedure based on a new approach. The technique consists of the advancement of an orbicularis oculi myocutaneous flap designed within the blepharoplasty skin excision pattern. METHODS: After the tumor's excision is completed with clear margins, the borders of the flap are incised down to the submuscular plane inside the classical pattern of upper eyelid blepharoplasty. Two myocutaneous triangles are excised on both sides of the flap to allow its advancement to cover the defect. When it is necessary to repair the posterior lamella, we harvest a mucochondral graft. RESULTS: From 2012 to 2015, we performed upper eyelid reconstruction with this technique on six patients. The flap survived in all the patients, without total or partial necrosis. No patient required surgical revision. The results were aesthetically satisfying, and no tumor recurrence was noted. CONCLUSIONS: Our new approach to upper eyelid reconstruction maximizes the cosmetic outcome respecting the principles of radicality. This flap is better suited for lesions involving the median or paramedian eyelid border from the marginal zone up to the palpebral crease. The approach we propose is safe and versatile, and it ensures either a functional or a good aesthetic reconstruction. 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 .

The Effect of the Short and Floating Columellar Strut Graft and Septocolumellar Suture on Nasal Tip Projection and Rotation in Primary Open Approach Rhinoplasty.

OBJECTIVE: The maintenance of desired tip projection and rotation is an important goal in rhinoplasty. In this study, the effects of the columellar strut graft and septocolumellar sutures were evaluated in a follow-up period of 1 year. PATIENTS AND METHODS: In half of 44 patients, nasal tip was constructed with basic tip maneuvers and two septocolumellar sutures (Group-1, Suture Group), whereas in the remaining 22 patients, a columellar strut graft was added for tip support (Group-2, Suture + Graft Group). Standardized right profile images were taken preoperatively, 1 month postoperatively and 1 year postoperatively. Nasal tip projection was evaluated using Goode's method. For the evaluation of tip rotation, the nasolabial angle was measured. The results were statistically compared, and a p value lower than 0.05 was considered as significant. RESULTS: Between the postoperative first month to first year, the loss of tip projection was 3.8% in Group-1 and 3.5% in Group-2 which was statistically insignificant (p value 0.942). The loss of tip rotation was found as 4.6° (4.1%) in Group-1 and 4.6° (4.0%) in Group-2 which was also statistically insignificant (p value 0.979). CONCLUSIONS: Considering the results of the study, in most of the primary cases, two septocolumellar sutures in conjunction with basic tip maneuvers are sufficient for positioning and stabilizing of the nasal tip, and a short and floating columellar strut graft does not have any affect in maintenance of the desired nasal tip rotation and projection. LEVEL OF EVIDENCE III: 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 A3 online Instructions to Authors. www.springer.com/00266 .

The Effect of Nasal Tip Rotation on Upper Lip Length.

Background: Increasing the nasolabial angle (NLA) with tip rotation generates the appearance of a lengthened lower facial third. In particular, the upper lip show seems increased following elevation of the nasal tip. Objectives: The purpose of this study is to quantify the impact of tip rotation on upper lip length (ULL), and to establish a predictable correlation between the two. Methods: A retrospective cohort study of rhinoplasty patients with increased tip rotation, using either caudal septal extension graft (CSEG) or columellar strut graft (CS), was performed. Three-dimensional photos were obtained and analyzed anthropometrically and used to measure the ULL and NLA. The deltas between NLA and ULL at the various time points, was then compared using linear regression with P < .05 recognized as statistically significant. Results: One-hundred and fifty patients were identified and 88 patients met inclusion criteria. CS and CSEG were used in 40% (n = 36), and 60% (n = 52), respectively. Three-dimensional assessment showed that as the NLA positively correlated with the ULL in both cohorts. The CSEG group created a greater NLA and ULL compared to the CS cohort. Both NLA and ULL decreased over time, but remained statistically increased as compared with preoperative measurements. For every one degree of NLA increase, the ULL increases by 0.05 mm. Conclusions: Increasing nasal tip rotation in rhinoplasty results in greater upper lip show. Both CS and CSEG can effectively increase tip rotation and ULL. A predictable correlation of nearly 0.05 mm of ULL for every 1 degree of tip rotation is shown. Level of Evidence: 4.

Tip-Oriented Closed Rhinoplasty Built on Septocolumellar Suture and a New Caudal Septal Graft Technique.

BACKGROUND: A beautiful and appealing nose receives the greatest contribution from the nasal tip subunit, which should be regarded as the primary center of attention during a rhinoplasty procedure. In achieving the desired shape and position of the nasal tip during closed rhinoplasty, the septocolumellar suture functions as the major determinant together with the caudal portion of the septal cartilage, which has a significant influence on the versatility of the septocolumellar suture. The purpose of this study was to present the analysis of the indications, the technical steps, and the advantages of caudal septal graft and septocolumellar suture utilization in closed rhinoplasty. METHODS: The septocolumellar suture with or without the caudal septal graft combination procedure has been performed in 2286 patients via a closed rhinoplasty approach. Intraoperatively, the septal cartilage at hand was thoroughly evaluated and one of the 5 types of caudal septal grafts was used when necessary. After the establishment of a strong and straight septal cartilage with sufficient height and length, 4 different septocolumellar sutures in a specific order were used to modify the relationship between the lower lateral cartilages and the nasal septum. RESULTS: Of the 2286 cases, 1837 (80.3%) were primary and 449 (19.7%) secondary rhinoplasties, which have been followed up for 9 to 48 months. The caudal septal graft was combined to the septocolumellar suture in 621 (27.1%) patients. Of the caudal septal grafts, 69.7% were used for primary rhinoplasty cases, and 30.3% for secondary rhinoplasties. At the 18th month postoperatively, tip projection was found to be satisfactory for 98% of the patients. CONCLUSIONS: The septocolumellar suture combined with caudal septal graft in closed rhinoplasty substantially facilitates the achievement of a cosmetically and functionally pleasing end result, bringing the solution for a wide array of problems such as short nose, supratip deformity, nasolabial angle change, or columellar bowing. Nevertheless, the technique has a steep learning curve; therefore, a meticulous preoperative evaluation should be exerted, a precise surgical planning should be prosecuted, and an excessive reduction of the nasal tip or exaggerated columellar retraction should be avoided.