Sequential Assessment of External Nasal Deviation Angle Changes in Patients With a Deviated Nose Who Underwent Bilateral Osteotomy.

OBJECTIVE: A deviated nose is traditionally classified as bony, cartilaginous, or combined deviation. Osteotomy is commonly used to correct bony deviation, and accurate surgical techniques and postoperative patient management are important for favorable outcomes. The authors investigated the change in the external nasal deviation angle over time using sequential clinical photographs to identify the optimal postoperative follow-up duration. METHODS: Medical records and sequential standardized clinical photographs of 22 patients who underwent bilateral medial and lateral osteotomies without dorsal augmentation from January 1, 2014 to May 31, 2021, were retrospectively reviewed. Clinical photographs were classified into 4 periods: "a" preoperative, "b" postoperative day (POD) ≤3 weeks, "c" POD ≤9 weeks, and "d" POD >9 weeks. The angle of deviation (AoD) was measured in both frontal and chin-on-chest views for each period. Differences in AoD between temporally adjacent periods were analyzed. RESULTS: Nineteen men and 3 women (mean age: 28.8 y) were included. Thirteen patients showed rightward deviation, whereas 9 showed leftward deviation. Eleven patients underwent surgery through an endonasal approach, whereas the other 11 underwent surgery through an external approach. In the frontal view, AoD differences (mean ± SD) between periods "a" and "b," "b" and "c," and "c" and "d" were 5.79 ± 3.36 degrees (P < 0.001), 1.44 ± 1.14 degrees (P < 0.001), and 1.07 ± 1.24 degrees (P < 0.05), respectively. In the chin-on-chest view, the values were 5.17 ± 2.69 degrees (P < 0.001), 2.06 ± 2.63 degrees (P < 0.001), and 1.46 ± 1.31 degrees (P < 0.001), respectively. No statistically significant difference in AoD differences was observed between the two approaches. CONCLUSIONS: Angle of deviation can change even 9 weeks after bilateral osteotomy. Thus, long-term follow-up using sequential clinical photographs is mandatory. If needed, close follow-up with early postoperative interventions may be required. The chin-on-chest view showed better sensitivity for assessing AoD than the frontal view.

Crossing Borders: 95. Jahresversammlung der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie vom 8. bis 11. Mai 2024 in Essen. / Crossing Borders: 95. Jahresversammlung der Deutschen Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie vom 8. bis 11. Mai 2024 in Essen.

Dear colleagues,Dear readers,We are constantly developing innovative solutions and treatment concepts for our patients in our discipline. In this context, interdisciplinary collaboration is essential. The conference motto "Crossing Borders: interdisciplinary, international, interactive" of the 95th Annual Meeting of the German Society of Otorhinolaryngology, Head and Neck Surgery emphasizes the relevance of interdisciplinary cooperation and global exchange. This year, joint meetings with the European Laryngological Society (ELS) and the Rhinoplasty Society of Europe (RSE) will take place for the first time. The American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) and the Confederation of European Otorhinolaryngology - Head and Neck Surgery (CEORL-HNS) are also involved in the scientific program. The interdisciplinary presentations offer insights into the most recent developments in the fields of head and neck oncology, skull base and orbital surgery, among others. They are a great opportunity to expand your own knowledge and exchange the latest research findings.

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

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

Treatment of congenital melanocytic naevi of nose using multiple flaps in single stage in a paediatric patient and literature review.

A girl in her middle childhood presented to the outpatient department (OPD) with a congenital melanocytic naevi (CMN) of the right nasal alar lobule. Her parents had aesthetic concerns and expressed their desire to get the lesion removed. The full-thickness excision of CMN was performed with the reconstruction of the defect using the nasolabial and dorsal nasal advancement flap with conchal cartilage to shape the contour of the ala.

Injectable Cartilage Microtissue Regenerated by Autologous Chondrocytes for Nasal Augmentation: A 5-Year Follow-Up Study.

BACKGROUND: A lack of ideal filling materials is a critical limitation in current rhinoplasty. Cartilage sheet regeneration by autologous chondrocytes is expected to provide an ideal source of material. However, the inability to perform minimally invasive transplantation of cartilage sheets has greatly limited the clinical application of this material. In this article, the authors propose the concept of injectable cartilage microtissue (ICM) based on cartilage sheet technology, with the aim of achieving minimally invasive augmentation rhinoplasty in clinical practice. METHODS: Approximately 1.0 cm2 of posterior auricular cartilage was collected from 28 patients. Isolated chondrocytes were expanded, then used to construct autologous cartilage sheets by high-density seeding and in vitro culture in chondrogenic medium with cytokines (eg, transforming growth factor beta-1 and insulin-like growth factor-1) for 3 weeks. Next, ICM was prepared by granulation of the cartilage sheets; it was then injected into a subcutaneous pocket for rhinoplasty. RESULTS: ICM was successfully prepared in all patients, and its implantation efficiently raised the nasal dorsum. Magnetic resonance imaging confirmed that regenerative tissue was present at the injection site; histologic examinations demonstrated mature cartilage formation with typical cartilage lacunae and abundant cartilage-specific deposition of extracellular matrix. Excellent or good postoperative patient satisfaction results were achieved in 83.3% of patients over 5 years of follow-up. Obvious absorption of grafts occurred in only two patients (8.3%). CONCLUSIONS: These results demonstrated that ICM could facilitate stable cartilage regeneration and long-term maintenance in the human body; the implantation of ICM enabled natural augmentation of the depressed nasal dorsum. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Surgery is better than nasal sprays for people with severely blocked airways caused by septal deviation.

The studyCarrie S, O'Hara J, Fouweather T, et al. Clinical effectiveness of septoplasty versus medical management for nasal airways obstruction: multicentre, open label, randomised controlled trial. BMJ 2023;383:e075445.To read the full NIHR Alert, go to: https://evidence.nihr.ac.uk/alert/surgery-is-better-than-nasal-sprays-for-people-with-severely-blocked-airways/.

Development of an Algorithm to Determine Which Costal Cartilage to Harvest.

Rib graft is a common source of cartilage in rhinoplasty. Donor site choices for this resource were identified according to the authors who presented the introduction of this technique. However, the scientific basis of this valuable method lacks information, including the anatomical properties of costal cartilage. In this study, cartilage radioanatomy is examined and tested for if any estimators are present. A total of 148 thoracal CT scans of patients who applied to our facility were analyzed. Patients were divided per their sex and age of 35, and rib cartilage dimensions, including axial length between the sternal and costal ends of the cartilage (TotL), posteroanterior diameters at the sternal end (StDia), costal end (CosDia), the thickest part (MaxDia) as diametrical parameters and vertical height at the thickest part (h) were recorded. Length of the sternum (St), the axial length of the clavicle (ClavL), the distance of the sixth rib from the anterior axillary border (AntAx), and thorax circumferences at the level of both pectoralis major muscle origin (ThC) and nipples (BrC) were recorded. Statistical analyses were done for correlations. St, ClavL, ThC, and BrC were found to have the most correlated measurements in groups with the age of 35 and less of both genders, and the relations were lost in older groups. Thorax shape may change after the age of 35 years, but in younger patients, St in females and ClavL in males can be used as estimators of cartilage amount.

Columella Reconstruction Using a Bilateral Nasolabial Flap: A Case Report.

BACKGROUND The columella has many fundamental functions, such as nasal breathing and support of the nasal tip, in addition to the aesthetic role it plays. The columella is one of the most difficult nasal subunits, both from the point of view of disease control and from that of reconstruction. Lesions involving the columella can be difficult to control, and malignancies can spread to the septum, subcutaneous tissues of the lip, and floor of the nasal cavities. Many columella reconstruction methods after resection have been proposed (local nasal flaps, skin grafts, regional flaps, free flaps), depending on the size of the defect, patient's features, surgeon's experience, and patient's aesthetic wishes. CASE REPORT We present a case of an 82-year-old woman with various comorbidities who had squamous cell carcinoma (G2) originating from the skin of the right side of the columella. The lesion infiltrated the cartilage, arriving to the skin of the columella on the left side and extending to the mucosa of the nasal septum bilaterally. Reconstruction was conducted using a bilateral nasolabial flap, with good functional and aesthetic result. Surgical revision for the autonomization of pedicled flaps was not necessary, nor desired by the patient. CONCLUSIONS The bilateral nasolabial flap is an effective and safe solution for reconstructing the columella, with good support of the tip even without cartilaginous graft. This technique is especially feasible in elderly patients and those with concomitant pathologies, who benefit from rapid healing of the wound.

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

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

Decision Making in Nasal Reconstruction: When to Use the Forehead Flap?

In this review, the paramedian forehead flap indications and uses are reviewed, specifically examining clinical situations where patient selection is important. In these settings, a preoperative discussion with a patient regarding surgical expectations and goals in the setting of their defect is paramount. The authors review the literature regarding the psychosocial aspects of major nasal reconstruction and review preoperative discussion points that are key to a well-informed patient and improved patient satisfaction through the nasal reconstructive process.

Nasal Reconstruction of Large Defects Without a Forehead Flap.

Defects over 2.0 to 2.5 cm may often require repair with a multistaged forehead flap. However, in some such defects, other options may be available. In this article, the author will review some of these options.

Implications of Malignancy, Radiation, and Timing of Major Nasal Reconstruction.

Owing to the complex, multilayered anatomy of the nose in the central face, major nasal reconstruction can pose a significant challenge for reconstructive surgeons. It is the responsibility of reconstructive surgeons to have an understanding of the most common cutaneous malignancies and excisional techniques that may lead to complex nasal defects. The purpose of this article is to discuss these malignancies, excisional techniques, and impacts of radiation on tissue that has implications for reconstructive surgeons.

Nasal Lining Reconstruction with Prelaminated Forehead Flap.

A successful nasal reconstruction relies heavily on a stable internal lining. Larger defects pose unique challenges for internal lining reconstruction as obtaining tissue of adequate size while maintaining airway patency is difficult. The prelamination technique uses a staged skin graft to the paramedian forehead flap prior to transfer. As such, a composite flap can be later transferred to reconstruct internal and external nasal defects concomitantly. This article reviews the current background, techniques, and clinical considerations in the use of the prelaminated forehead flap for nasal lining reconstruction in partial to total nasal defects.

Total Nasal Reconstruction: Advances in Free Tissue Transfer for Internal Lining and Structural Support.

Total nasal reconstruction is a complex challenge due to the need to establish new internal lining, internal structural support, and external skin covering that is both functional and esthetic. The medial femoral condyle corticoperiosteal free flap represents an innovative option for restoration internal structure and internal nasal lining. When used in conjunction with a paramedian forehead flap, acceptable results in both function and esthetics can be achieved.

Structural Support for Large to Total Nasal Reconstruction.

When large defects of the nose are present, it is imperative to address all 3 layers: the external skin envelope, the osteocartilaginous support, and the inner mucosal lining. The middle structural framework is the primary factor in determining the overall shape of the nose, in addition to facilitating a functional and patent airway. As such, its reconstruction must be robust enough to provide lasting osteocartilaginous support while minimizing disfiguring bulk. The goal is replacement of missing tissue with grafts of similar strength, size, and shape. This article will review approaches to the reconstruction of structural support in large nasal defects.

Nuances in Forehead Flap Reconstruction for Large Nasal Defects.

The forehead flap is a time-tested and robust resurfacing flap used for nasal reconstruction. Owing to its excellent color and texture match, acceptable donor site morbidity, and robust and independent blood supply that can support both structural and internal lining grafts, this flap remains the workhorse flap for resurfacing large nasal defects. Various nuances of this technique relating to defect and template preparation, flap design, flap elevation, flap inset, donor site closure, and pedicle division are discussed in this article. These nuances are the guiding principles for improved outcomes using a forehead flap for the reconstruction of large nasal defects.

Nasal Lining Reconstruction with Loco-regional Flaps.

The reliability of local intranasal flaps speaks to the robust vascularity of the nose, which these flaps are based on. The goals for lining replacement, as in any other area of head and neck reconstruction, is to use tissue that best matches the qualities of what is being replaced. The goal of this review is to describe the extent to which local tissues can be used and when to consider regional flaps when the extent of a local flap will not provide enough coverage.

Reconstruction of Large Composite Defects Extending Beyond the Nose.

Nasal reconstruction remains one of the most challenging surgeries for facial plastic and reconstructive surgeons. The addition of defects extending beyond the nose adds a layer of complexity to an already technically demanding surgery. This article will focus on the management of composite defects extending beyond the boundaries of the nose. Surgeons need to have a variety of techniques at their disposal. These complex defects often require multiple local flaps, multiple stages, and, in select cases, free tissue transfer.