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.

The Composite Spreader Flap.

Background: The effect of a spreader flap on the keystone area and the upper bony vault depends on the structural strength and cephalic extent of upper lateral cartilages, both of which can be significantly variable among individuals. Objectives: The authors present a novel cephalically extended osseocartilaginous composite spreader flap technique that was designed to overcome the limitations of a conventional spreader flap on the keystone area upper bony vault, in patients with cephalically short and structurally weak upper lateral cartilages and thin nasal bones. Methods: This study was a retrospective review of the recorded perioperative information to investigate the frequency of the use of the composite spreader flap technique and perioperative parameters that relate to postoperative dorsal deformities. One-hundred-seventy-six consecutive primary open approach rhinoplasty cases performed by the first author (O.B.) between November 2015 and February 2017 were included in the study. Patient data were obtained from rhinoplasty data sheets, standardized photographs, and postoperative physical examinations. Results: Of the 176 cases who underwent primary open approach rhinoplasty whose data were reviewed for the purpose of this study, 38 (32 females, 6 males) had dorsal reconstruction with the use of a composite spreader flap. Seventeen patients had a deviated nose with an asymmetric bony pyramid. In 8 patients, the composite spreader flap was used unilaterally. No patients in the composite spreader flap group had a postoperative dorsal deformity or required surgical revision. Conclusions: Composite flap preparation extends the reliability and the reach of the spreader flap technique beyond its previous borders.

Found in space: computer-assisted orthognathic alignment of a total face allograft in six degrees of freedom.

PURPOSE: Full facial osteomyocutaneous transplantation requires correct 3-dimensional (3D) alignment of donor osseous structures to a new cranial base with minimal reference points and 6 degrees of potential movement. We investigated whether computer-assisted design and manufacturing (CAD/CAM) could enable accurate placement of the facial skeleton. MATERIALS AND METHODS: A prospective single-cohort study of Le Fort III-based maxillary-mandibular segment allotransplantation was performed in 5 cadaver pairs and 1 clinical pair. The osteotomies were modeled using computed tomography (CT) data and 3D modeling software and then translated to the donor-recipient pairs using surgical navigation and osteotomy cutting guides. The predicted values were calculated about all rotational axes (pitch, yaw, and roll) and along all translational axes (vertical, horizontal, and anteroposterior) and used as the independent variable. The primary outcome variable of the actual postoperative CT values was compared for fidelity to the prediction using the intraclass correlation coefficient (ICC). The similarity to the donor versus recipient values was calculated as a secondary independent variable, and both predicted and actual measurements were compared with it as a percentage. RESULTS: The postoperative fidelity to the plan was adequate to excellent (ICC 0.520 to 0.975) with the exception of lateral translation (2.94 ± 1.31 mm predicted left vs 3.92 ± 2.17 mm right actual displacement; ICC 0.243). The predicted and actual values were not consistently skewed toward the donor or recipient values. CONCLUSIONS: We have demonstrated a novel application of CAD/CAM that enables orthognathic alignment of a maxillary-mandibular segment to a new cranial base. Quantification of the alignment in all 6 degrees of freedom delivers precise control compared with the planned changes and allows postoperative quality control.

Postoperative effects of anterior nasal spine bone harvesting on overall nasal shape.

AIM: Bone harvesting from the anterior nasal spine (ANS) is frequently used to correct peri-implant bone defects, particularly during implant placement in the anterior maxilla. However, many clinicians are concerned about the postoperative effect of removing the ANS on the nasal outline, as the ANS is integral to supporting the nose. This study aimed to describe the technique of ANS bone grafting and to investigate postoperative effects of bone harvesting from the ANS on the overall nasal shape. MATERIAL AND METHODS: Fifteen patients with single maxillary first incisal rehabilitation using dental implant were enrolled in this prospective clinical study. Simply by extending the subperiosteal dissection in the same surgical field without additional local anesthesia, a bone block of about 0.25-0.5 ml could be harvested from the ANS. Nose width (NW), nasolabial angle (NLA), and nasal tip depth (NTD) were measured and analyzed by lateral and frontal photographs taken preoperatively (T0), and at postoperative 1 week (T1), 3 months (T2), and 6 months (T3). Postoperative complications were also recorded. RESULTS: A significant increase in NW and decrease in both NLA and NTD were found at T1 (P < 0.05). At T3, NW, NLA and NTD returned to preoperative measurements at T0 without major complications. CONCLUSIONS: The ANS could be an effective and easily accessible intraoral source for autologous bone. Despite acute soft tissue swelling, the net postoperative effects of removing the ANS on the overall nasal shape, including on nasal tip collapse or widening of the nose base, were negligible.

Primary alveolar bone grafting and gingivoperiosteoplasty or gingivomucoperiosteal flap at the time of 1-stage repair of unilateral cleft lip and palate.

It takes quite a long time to finish treating patients with cleft lip and palate. Usually, lip closure, palate repair, secondary alveolar bone grafting, and secondary repair of lip/nose have been given to patients at appropriate time according to their growth. However, these series of surgical interventions impose a considerable burden on the patients and their families. As for palate repair, it is considered that the earlier the better for the sake of speech, but it should be delayed to approximately 1(1/2) years of age for maxillary growth. However, we have developed a palate repair technique that will hardly result in marked maxillary growth impairment by modifying the Furlow method, so we have become able to perform palate repair between 3 and 10 months after birth. Accordingly, we can perform lip and palate repair simultaneously, which have been performed separately. As we have developed a 1-stage repair of cleft lip and palate including primary alveolar bone grafting from nasal concha and/or hard plate and gingivoperiosteoplasty or gingivomucoperiosteal flap, we report on our technique and treatment outcome.

The Use of Bone Dust to Correct the Open Roof Deformity in Rhinoplasty.

BACKGROUND: Hump removal frequently results in an open roof during rhinoplasty, which is conventionally closed with lateral osteotomies. However, if the patient has a narrow bony vault, lateral osteotomies are problematic. In this article, the author presents a new and practical approach to fix the open roof deformity. METHODS: A total of 240 patients (female, n = 187; male, n = 53) were enrolled and operated on with the presented technique. This approach has four steps, as follows: complete submembranous dissection, preparation of spreader flaps, harvesting of bone dust from the bony hump, and placement of the bone dust. The patient's nasal dorsum was evaluated by ultrasonography. During the follow-up period, all patients were photographed postoperatively from standard views using a digital camera. Photographs were inspected by two independent plastic surgeons. A palpation test for the nasal dorsum was conducted by a senior surgeon to identify any irregularities. A rhinoplasty outcomes evaluation questionnaire was administered to all patients at a 1-year follow-up visit. Functional improvement was assessed with self-evaluation of nasal patency. The chi-square test was used for statistical analysis. RESULTS: Of the 240 patients, 182 completed the 1-year follow-up period and rhinoplasty outcomes evaluation questionnaire. Thirty-seven patients were evaluated by ultrasonography at 1 year postoperatively. During the follow-up period, no resorption or displacement was detected. High patient satisfaction was achieved, and no complications were encountered. CONCLUSION: The presented four-step surgical concept was useful for rhinoplasty surgeons to successfully manage open roof deformity in selected patients.

The hump columellar strut: a reliable technique for correction of nasal tip underprojection.

Nasal tip under projection is often found in rhinoplasty cases both for congenital or post-traumatic deformity. Nasal trauma may result in alteration of the external and internal nasal structures with following aesthetic impairment and difficulties in breathing. Post-traumatic surgery is frequent, but restoration of pre-traumatic form and function remains a challenge. The present paper describes a new method to increase tip projection by a columellar strut harvested from the autologous nasal bone and cartilage of the resected hump. A total of 15 cases (11 women/4 men, mean age 32.6 ± 12.3 years) of major tip projection/misalignment abnormalities to be corrected by increased nasal tip projection were drawn, and all underwent closed or open rhinoplasty with the placement of a bony columellar strut harvested from the resected hump of the patient. Short and long-term advantages of this procedure are to be underlined. Harvesting is routinely performed during dorsal resection and preparation of the graft is easy. Differently from bone of the vomer or the inferior turbinate, this is cortical bone straight in shape and rigid in framework, and therefore ideal to gain reliable tip support overtime. No additional harvesting areas are needed. Placement of this bony strut is carried out in the standard fashion without additional dissection or further procedures. Long-term follow-up shows maintained projection over time. This graft can be combined with various grafting or suturing techniques usually applied according to each surgeon's experience and the needs of each patient.

Atypical cyst formation following chin augmentation using a nasal osteocartilaginous graft.

The purpose of this paper is to present a case of an intraosseous mucocele that was detected 5 years after chin augmentation using a nasal osteocartilaginous graft. Although complications of this technique have been described as negligible, the surgeon must be aware of possible long-term side effects and should remove all nasal mucosa from the graft prior to implantation.

Respiratory epithelium in a mandibular cyst after grafting of autogenous bone.

The case of an interesting mandibular cyst is presented. The pathogenesis of this cyst may be related to implantation of epithelial remnants in an autogenous graft to the recipient tissues during previous cosmetic surgery. With the proliferation of methods involving tissue transfer to the maxillofacial region, the possibility of the transfer of potentially pathogenic material needs to be considered.

Radix grafts in cosmetic rhinoplasty: lessons from an 8-year review.

We describe our experience with radix augmentation during cosmetic rhinoplasty over an 8-year period using both autologous and synthetic grafts and provide insight into maximizing success. We discuss various surgical considerations, including patient selection, graft materials, and dealing with complications. We focus on our operative technique and provide patient examples.

[An endoscopic approach to reconstruction of skull base defects using a vascular pedicled nasoseptal mucoperiosteal flap].

OBJECTIVE: To introduce a method and the clinical effects of repairing skull base defects and dural defects using vascular pedicled nasoseptal mucoperiosteal flaps through an endoscopic endonasal approach. METHODS: The clinical and follow-up data for 8 patients who underwent endoscopic endonasal reconstruction of skull base defects and cerebrospinal fluid rhinorrhea with a vascular pedicled nasoseptal mucoperiosteal flap between July 2008 and March 2010 were retrospectively reviewed. All patients were male. The age of these patients ranged from 28 to 60 years (average 41 years). The diagnosis for these patients included one hemangiopericytoma of the anterior skull base one olfactory neuroblastoma (type of Kadish C), one ethmoid sinus cancer, three local recurrent cancers of the nasopharynx after radiotherapy, one carcinoid of skull base and one traumatic cerebrospinal fluid rhinorrhea with recurrent intracranial infection. There were six anterior skull base defects and two middle cranial fossa defects. An endoscopic endonasal surgical approach was used for the repair. A pedicled flap using the nasal septal mucoperiosteum based on the posterior nasal artery was harvested from the ipsilateral side. The tissue flap was used to cover the dural defects. The margin was covered with gelatin sponge and fixed with fibrin glue. The nasal cavity was packed with iodoform gauze, a Foley catheter balloon and Merocel in this sequence to secure the flap in place. Nasal packing was removed 5 to 7 days postoperatively. RESULTS: Partial septal flap necrosis was found in one case, but the flaps in the other 7 cases survived. A postoperative cerebrospinal fluid leak occurred in one case 7 days after surgery. This was re-explored and successfully repaired with abdominal fat. All cases healed well, with no delayed cerebrospinal fluid leaks or intracranial infections during the 6 to 24 months follow-up period. CONCLUSION: The vascular pedicled nasoseptal mucoperiosteal flap is a reliable choice for endoscopic endonasal skull base reconstruction.

Augmentation mentoplasty with osteocartilaginous nasal graft.

OBJECTIVE: Augmentation mentoplasty is a common procedure, applied especially in conjunction with rhinoplasty. Although various materials have been used, autogenous nasal hump tissue has not been studied in a big series of patients. The main objective of this study was to evaluate the use of autogenous nasal hump in chin augmentation. STUDY DESIGN: Case series with chart review. SETTING: University hospital. SUBJECTS AND METHODS: The osteocartilaginous mentoplasty procedure was performed in 124 patients along with rhinoplasty in a series of 218 patients who had undergone combined rhinoplasty and mentoplasty with various techniques. The median follow-up was 58 months (range, 12-120 months) over a 10-year period. The procedure commenced under general anesthesia for all patients with large humps and poor chin projection. During the rhinoplasty procedure, the osteocartilaginous nasal hump was removed, tailored to achieve an anatomic mental form, and inserted into the mental pocket through a submental or an intraoral incision. RESULTS: Infection was detected in five patients, two of whom required graft removal. All other patients recovered normally along an almost painless process, without displacements or any other complaints. CONCLUSION: Nasal hump in reduction rhinoplasty is a useful alternative for augmentation mentoplasty on patients with large humps and poor chin projection. It also avoids all the disadvantages of alloplastic materials and eases integration compared with other alternatives in selected cases.

A different approach to the reconstruction of the stubborn crooked nose with a different spreader graft: nasal bone grafts harvested from the removed nasal hump.

BACKGROUND: Correction of a crooked or deviated nose is a complex cosmetic and functional problem as well as a big challenge for the rhinoplasty surgeon. Although corrections using a wide range of surgical techniques to straighten the nose and maximize nasal function have been proposed, recurrence is very common because of cartilage memory and scar contracture. Therefore, to prevent recurrence and maintain the correction of the septum, a permanent support that is stable and strong with the ability to maintain its given shape after placement on one or both sides of the septum is needed. METHODS: The author used a nasal bone graft. In this study, the concept and technique for correction of the crooked nose and the author's experience using it are presented. RESULTS: This graft material was used for 12 patients with crooked noses (8 with C-type and 4 with S-type noses). During a mean follow-up period of 20 months (range, 12-36 months), there were no complications, recurrences, or extrusions. Functional evaluations were performed using a visual analog scale before surgery and 6 months after surgery. Patients were asked to score their nasal breathing on a scale ranging from 0 to 100. The mean preoperative value was 17.67% +/- 1.22% (range, 15-25%), and the postoperative value was 89.88% +/- 1.24% (range, 85-95%). CONCLUSION: Use of nasal bone grafts as the spreader graft is a safe, effective, reliable, and permanent method for correction of the crooked nose. The author advises using this technique with nasal bone grafts for functional recovery and increased strength against further trauma or forces of scar contracture. This technique may prevent recurrence attributable to cartilage memory.

Columella implants. Reconstruction of the anterior septum.

A follow-up study was conducted of implants used to replace the anterior septal cartilage. The implants used were (1) the cartilaginous septum after correction, (2) parts of the bony septum (when it was impossible to use the cartilaginous septum), (3) or bank cartilage (when there was insufficient autograft material). One hundred cases were examined 12 months after surgery and divided into three groups according to the material used. There was no statistical difference between the percentages of satisfactory results in the three groups: 66% satisfactory and 33% unsatisfactory. Further analysis of the unsatisfactory results indicated that the most difficult feature is judging the size of the implant: too small an implant results in instability, reduction in the nasolabial angle, and retraction of the columella. Previous surgery increases the risk of poor results.

Use of isografts and homografts in reconstruction of the nasal pyramid.

A technique for the reconstruction of the nasal pyramid using nasal auto and homografts is presented. It permits the correction of functional problems and of the nasal appearance at the same time. In cases of autografts alone, the results have been satisfactory. In cases of homografts, 10% resorption has been experienced to date. However, since the authors complete with alar swing and nose lift procedures, they have had no significant nasal depression so far. Only the future will tell if this last technique is valuable.

Growth effects of differing oronasal flaps on rib grafts in the dog palate.

An experimental model was designed to test the hypothesis that the periosteum of the nasal cavity may have an inherent tendency for bone resorption whereas oro-palatal periosteum may have an inherent osteogenic character. This hypothesis was found to be valid and could have important surgical implications in man.