[Cartilaginous graft in rhinoplasty]. / Greffes cartilagineuses en rhinoplastie.

Nowadays, cartilage grafts are widely used in secondary as well as primary rhinoplasty. Even if their fixation is often easier and more precise using an open approach, most of them can also be positioned with a close approach. In this article, the authors describe various cartilage donor sites. For each of them, they describe benefits, inconveniences, harvesting techniques and preferred indications. Cartilage can be harvested on the septum, ear and ribs. For the authors, septal cartilage is often the best material but can be insufficient or totally missing (especially in secondary rhinoplasty). In such cases, concha cartilage is a good material for tip and alar grafts because of its pliability and convexity whereas rib cartilage, which is stiffer and thicker, will provide good supporting grafts. Described more recently, diced cartilage wrapped in fascia (DCF) can be a very good option for dorsal onlay graft, avoiding irregularities of conchal cartilage and risk of rib cartilage's twisting.

[Middle third of the nose and internal valve. Alar wall and external valve]. / Tiers moyen du nez et valve interne. Paroi alaire et valve externe.

To many surgeons, nasal airway obstruction is synonymous with either septal deviation or inferior turbinate hypertrophy. The role of internal and external nasal valves is often less known by surgeons even if it is crucial in nasal breathing and strongly interrelated with esthetic of the middle third of the nose and alar wall. Therefore, precise examination of the two valves and conservative surgery should help to avoid many functional and esthetic problems.

[Over projected tip]. / Pointe du nez hyper-projetée.

Overprojected tip is a pretty usual request not easy to manage. Preop analysis is crucial in order to evaluate tip support and skin thickness and ability to retract. For example, if the skin is very thick and has poor chance to retract, the surgeon should be very careful in the tip projection decreasing to avoid a skin pollybeak deformity. In such cases, he has to analyze the facial proportions, especially other areas projection (radix, dorsum and chin) and think about augmenting them to balance the profile rather than decreasing tip projection. Correction should always be conducted incrementally, starting with weakening the tip support mechanisms and, only if necessary, continue with alar cartilage interruption. This can be performed on many areas (lateral cruras, domes, medial cruras) and with several techniques (resection or interruption+overlapping).

[Osteotomies in rhinoplasty]. / Ostéotomies en rhinoplastie.

Osteotomies are performed to modify the shape of the bony part of the nose, therefore they should not be done systematically. Main indications are correction of deviated nose, narrowing of bony vault and roofing of an open roof after important hump resection. The nose should be very precisely analyzed before osteotomies if the surgeon doesn't want to create deformities such as step, inverted V, pinched nose or saddle nose. When too narrowed, bones can also block the airway and lead to functional problems.

[Tip sutures]. / Sutures de la pointe du nez.

Suture techniques are widely used and can be very useful and efficient to support the nasal tip and correct its deformities. Nevertheless, they are so powerful that they have to be performed very precisely if the surgeon does not want to create cosmetics as well as functional problems. The authors describe the main tip sutures and their effects, expected or not.

[Secondary rhinoplasty]. / Rhinoplastie secondaire.

Secondary rhinoplasty is very usual. Some patients are not satisfied by the previous surgery because the result is poor with obvious defaults but, sometimes, the result is good but the patient expects perfection. These two different situations will not lead to the same answer from the surgeon. Techniques of secondary rhinoplasty are the same than primary, but are often more difficult to perform because of scar tissue, retraction and loss of lining. The authors analyse the more frequent deformities in secondary rhinoplasty and the way they fix them.

[Surgical approaches in rhinoplasty]. / Voies d'abord en rhinoplastie.

In the first step of rhinoplasty, the surgical approach will expose through different types of incisions and dissection planes the osteocartilaginous framework of the nasal pyramid prior to performing actions to reduce or increase the latter. This exposure can be performed by a closed approach or by an external approach--the choice depends on the type of nose and the habits of the surgeon. Far from being opposites, closed and external approaches are complementary and should be known and mastered by surgeons performing rhinoplasty.

[Preoperative analysis in rhinoplasty]. / Analyse préopératoire en rhinoplastie.

Preoperative analysis in rhinoplasty consists in analyzing individual anatomical and functional characteristics without losing sight of the initial requirements of the patient to which priority should be given. The examination is primarily clinical but it also uses preoperative photographs taken at specific accurate angles. Detecting functional disorders or associated general pathologies, which will reduce the risk of complications. All of these factors taken into account, the surgeon can work out a rhinoplasty plan which he or she will subsequently explain to the patient and obtain his or her approbation.

[Nostril surgery]. / Chirurgie cutanée des bords libres et des ailes narinaires.

The decision to perform nasal resection follows a comprehensive analysis of the aesthetic objective depending on the anatomic and artistic criteria. Fear of leaving visible scars leads many surgeons to hesitate vis-à-vis the indications. However, this surgical technique can be very useful during rhinoplasty. The patient should always be informed preoperatively of the possibility of cutaneous resection of the nostrils and the type of scar than can ensue. It is important to know the foreseeable elements of nasal resection in order to provide a more systematic approach to routine rhinoplasty.

[Surgical anatomy of the nose]. / Anatomie chirurgicale de la pyramide nasale.

Thorough knowledge of the anatomy of the nose is an essential prerequisite for preoperative analysis and the understanding of surgical techniques. Like a tent supported by its frame, the nose is an osteo-chondral structure covered by a peri-chondroperiosteal envelope, muscle and cutaneous covering tissues. For didactic reasons, we have chosen to treat this chapter in the form of comments from eight key configurations that the surgeon should acquire before performing rhinoplasty.

[Diced cartilage wrapped in deep temporal aponeurosis (DC-F): A new technique in augmentation rhinoplasty]. / Greffons cartilagineux en dés enroulés dans l'aponévrose temporale profonde (DC-F) : un nouveau procédé en rhinoplastie d'augmentation.

Diced cartilage rolled up in a fascia (DC-F) is a recent technique developed by Rollin K Daniel. It consists to tailor make a composite graft composed by pieces of cartilage cut in small dices wrapped in a layer of deep temporal aponeurosis. This initially malleable graft allows an effective dorsum augmentation (1 to 10 mm), adjustable until the end of the operation and even post operatively. The indications are all the primary and secondary augmentation rhinoplasties. However, the elective indications are the secondary augmentation rhinoplasties with cartilaginous donor site depletion, or when cartilaginous grafts are of poor quality (insufficient length, multifragmented...), or finally when the recipient site is uneven or asymmetrical. We report our experience of 20 patients operated in 2006 and 2007, with one year minimal follow-up. All the cases are relative or absolute saddle noses, idiopathic, post-traumatic or iatrogenic. Moreover, two patients also had a concomitant chin augmentation with DC-F. No case of displacement or resorption was noted. We modified certain technical points in order to make this technique even more powerful and predictable.

Treatment of over-reduction of the nose and subsequent deformities.

Failures after rhinoplasty are the result of both technical mistakes and of errors of judgement. One of the most common errors is resection of too much tissue from the components of the nose: the dorsum, alar cartilages, or septum. Such deformities may have both cosmetic and functional effects. The defects that most commonly make a nose look unnatural are: a shallow nasofrontal angle, a nose that has been shortened too much, an over-reduced dorsum which emphasises a parrot's beak deformity, and a round nasal tip with a short interdomal length that lacks definition. The purpose of this paper is to describe the most common deformities associated with excessive resection of the nose, and to suggest the appropriate procedures for correcting the defects. Grafting is usually necessary. We will deal first with deformities of the dorsum and septum and then of the nasal base, but it must be borne in mind that a defect in one area is likely to affect the other areas because they are interrelated-for example, over-resection of the dorsum may also effect the tip of the nose. In addition, not all deformities are the result of excessive reduction; some may result from inadequate resection.

[Rhinoplasty]. / Rhinoplastie.

The goal of rhinoplasty should not be necessarily a small nose but a nose which is well balanced with the face and fits with the individual. Increasing number of patients is linked with improvement of the techniques and it is frequent to see patients asking for correction of minor defects. Sequelae of rhinoplasty are still frequent but less severe, and even if their correction is difficult, it is possible in most cases, thanks to the use of cartilage grafts and external approach.

[Mini-forum: rhinoplasty by external approach. External or endonasal approach for rhinoplasty?]. / Mini forum: rhinoplastie par voie externe. Voie d'abord externe ou endonasale pour la rhinoplastie?

There appears to be a renewed interests in the external approach to rhinoplasty, first described 60 years ago, despite the external columellar incision, due to the excellent exposure of the cartilaginous structures provided by this approach. Progress has been made in rhinoplasty. Cartilage grafts are much more widely used than in the past and surgeons try to reconstruct a normal anatomy of the skeleton, which has become easier with this approach. However, the closed approach has demonstrated its efficacy for a long time and allows correction of a large range of deformities. The open rhinoplasty should not be the standard procedure and its indications should only be based on limitations of the closed approach. The external procedure is particularly indicated in some difficult cases of nasal tip surgery and secondary rhinoplasty.

[External transcolumellar approach and cartilage grafting: a very complementary association]. / Abord externe et greffes cartilagineuses: une association très complémentaire.

Two major facts have modified the philosophy of rhinoplasty: the desire to obtain more harmonious and balanced nose with conservative resections and a more frequent use of the open approach. This approach allows more accuracy in the diagnosis of the deformities and in the control and the preservation of the supports of the nose, namely the tip, alar and middle vault supports, and in the use of innovative techniques, specifically in the nasal tip: suture techniques and cartilage grafts. External transcolumellar approach and cartilage grafting go hand in hand and are frequently associated in the correction of under and overtip projection. Grafts can be use for improvement of aesthetic and function and the excellent exposure provided by the open approach permits a precise placement and stabilization of the grafts. Septal surgery benefits significantly from the excellent exposure for correction of all kind of deformities.

[Recent developments in esthetic rhinoplasty]. / Développements récents dans la rhinoplastie esthétique.

Over the last two decades, the concepts of cosmetic rhinoplasty have advanced, essentially due to the influence of J. Sheen. The importance of the anatomy of osteocartilaginous structures, their dynamic role, and the repercussions of their modification on the external shape has led to a more conservative surgery. Innovations have essentially concerned nose tip surgery and cartilage grafts. The revival of external approach and its popularity constituted the second major development; this can be explained by the direct, visualisation of cartilaginous structures and by the desire or necessity to preserve or reconstruct these structures. The indications for cartilage grafts have become more frequent and graft techniques have been developed and refined. The difficulties encountered in the use of autologous grafts have favoured the development of many new implants. Parietal cranial grafts occupy an increasingly important place in the indications for nasal bone grafts.