Auricular cartilage: harvest technique and versatility in rhinoplasty.

OBJECTIVES/HYPOTHESIS: This study aims to present an improved technique for auricular cartilage harvest that maximizes graft volume while preserving auricular cosmesis. Also discussed is the versatility of auricular cartilage utilization in rhinoplasty. STUDY DESIGN: A retrospective review of a single surgeon's experience. METHODS: All auricular cartilage harvest and rhinoplasty operations performed by the senior author (CSC) from December 2006 through December 2009 cartilage were reviewed. RESULTS: Twenty-two cases were identified in which the described technique was used to harvest auricular cartilage for the purpose of functional or aesthetic rhinoplasty. There was sufficient tissue harvested in all operations, and no patients required costal cartilage harvest. Pain at the donor site after surgery was minimal and well controlled with oral medication. There were no donor-site complications and no cases of wound infection. CONCLUSIONS: The proposed technique allows for optimal auricular cartilage harvest. By applying this method, the ear retains the preoperative appearance while the surgeon is able to obtain the largest graft possible. Auricular cartilage is a versatile source of grafting material in primary and secondary rhinoplasty.

Lateral Domal Translocation and Medial Crural Transection: A Reliable Method for Nasal Tip Deprojection.

SUMMARY: Nasal tip deprojection is a common goal in rhinoplasty. Several techniques have been described, many of which require destructive techniques that compromise the intrinsic integrity and morphology of the lateral crura. Through lateral translocation of the domes and shortening of the medial crura, nasal tip deprojection can be achieved without disrupting the integrity of the lateral crura. The domes are recreated lateral to the intrinsic domes with a standard transdomal suture, and excess length of the middle and medial crura is managed through transection and shortening of the medial crura. This technique preserves the morphology of the nasal base without altering the position of the medial crural footplates. Deprojection of 4 to 5 mm can be readily achieved with this technique.

A Simplified Approach to Nasal Tip Shaping: The Five-Suture Technique.

Techniques for nasal tip shaping have evolved from destructive to nondestructive techniques. These techniques have proven to be effective, yet they are often applied incrementally and require repeated intraoperative evaluation and manipulation to assess their efficacy. We describe a simple, effective, and reliable five-suture technique to achieve consistent results in tip shaping based on previously described ideals for nasal tip aesthetics.

Tragal cartilage grafts in rhinoplasty: a viable alternative in the graft-depleted patient.

OBJECTIVE: To describe a simple technique for harvesting tragal cartilage and describe its use in rhinoplasty. STUDY DESIGN: Retrospective review. SUBJECTS AND METHODS: Rhinoplasties performed between January 2005 and June 2007 in which tragal cartilage grafts were utilized by the senior author (CSC) were reviewed to assess type of graft, preservation of tragal contour, and donor-site morbidity. RESULTS: Tragal cartilage grafts were used in three primary and three secondary rhinoplasty patients. Postoperative follow-up ranged from six months to 12 months. Tragal cartilage was used as five alar contour grafts, one lateral crural onlay graft, one dorsal onlay graft, and one infratip lobule graft. Tragal cartilage was used to close the septal perforation of one patient. Tragal contour was preserved in all patients, and there were no complications noted with this procedure. CONCLUSION: The tragus provides a simple, convenient alternative source of cartilage for rhinoplasty in graft-depleted patients.

Current concepts in the postoperative care of the rhinoplasty patient.

This is a systematic review of the available literature and our own personal experience regarding the optimal management of the rhinoplasty patient. The routine utilization of nasal splinting, casting and perioperative antibiotics is supported. The management of a number of common early complications is also discussed. Meticulous technique based on sound structural principles and coupled with preoperative planning and attention to wound care will result in a favorable outcome in most individuals undergoing rhinoplasty.

Restorative rhinoplasty in the aging patient.

OBJECTIVE: The objective of this study is to review our favorable experience in performing rhinoplasty in aging patients. METHODS: All patients aged 65 years or greater who underwent rhinoplasty, either esthetic or functional, by the senior author (Y.D.) from August 1997 to July 2005 with a minimum follow up of 1 year were retrospectively reviewed. RESULTS: A total of 51 patients met the inclusion criteria and had complete records available for review. The average age was 69.5 years (range, 65-82 years) with 24 female and 27 male patients. All but two patients underwent open rhinoplasty. Eighteen procedures represented secondary rhinoplasties. Seven patients required auricular cartilage grafts, and 11 patients required costal cartilage grafts. One costal cartilage graft was aborted as a result of excessive calcification. All patients underwent columellar strut placement, 92% underwent internal valve grafts, and 80.4% underwent grafting of the external nasal valves. Nasal osteotomies were performed in only 23.5% of patients, all with the percutaneous technique. Revision surgery was necessary in only three (5.8%) patients, all of whom required grafting of the external valve (not performed primarily). In each of these cases, no significant external valve collapse was noted preoperatively. Premaxillary augmentation with diced or crushed cartilage grafts was performed in 81.8% (n = 18) of patients with an edentulous maxillary arch. CONCLUSIONS: Aging patients present unique technical challenges in rhinoplasty that warrant a comprehensive approach to restore internal and external valve competency and tip support. Consideration of prophylactic external valve grafts in addition to the routine use of internal valve grafts and columellar struts may help decrease the need for revision surgery in this patient population. Reasonable functional and esthetic outcomes can be expected in the aging patient.

Rethinking nasal osteotomies: an anatomic approach.

OBJECTIVES: To review our experience with our anatomic (medial, transverse, and lateral) nasal osteotomy technique for correcting the asymmetric bony nasal vault in esthetic and functional rhinoplasty. METHODS: All patients undergoing anatomic nasal osteotomy technique by the senior author (y.d.) from August 1997 to August 2005 with a minimum follow-up of 6 months were reviewed. Preoperative and postoperative photographs and clinical examination were analyzed to determine restoration of a symmetric bony nasal vault configuration. RESULTS: A total of 322 patients met the inclusion criteria. Percent of patients who had favorable results with restoration of a symmetric bony nasal vault configuration was 98.1%. Six (1.9%) patients required revision surgery at the level of the nasal bones with repeat osteotomies or dorsal rasping. All six of these patients had favorable outcomes after revision surgery. CONCLUSIONS: The anatomic nasal osteotomy technique represents an effective, simple, and logical approach for correcting asymmetric bony nasal vault.

Extended Alar Contour Grafts: An Evolution of the Lateral Crural Strut Graft Technique in Rhinoplasty.

Modification of the lower lateral cartilage complex is the sine qua non of modern rhinoplasty, and the open approach to rhinoplasty has expanded the number of techniques available to help achieve an aesthetically pleasing tip. The ideal tip has been described as having a diamond-shaped configuration, with the lateral points formed by the tip-defining points, the superior point by the supratip, and the inferior point by the columellar break point. Over the years, various techniques have been described to minimize isolation of the tip and to help achieve the ideal tip configuration: lateral crural strut grafts, alar contour grafts (i.e., rim grafts), alar strut grafts, subdomal grafts, and suturing techniques such as alar flaring sutures. The authors present their technique of the extended alar contour graft, which represents an evolution of the lateral crural strut graft and its marriage with the alar contour graft. Lateral crural abnormalities do not usually occur singularly, but rather are the result of an interplay of several factors. Nevertheless, the recurring theme of orientation and alar support to prevent isolation of the tip by extended alar grooves remains. Extended alar contour grafts are a versatile technique to optimize tip shape and orientation by combining the many positive attributes of lateral crural strut grafts and alar contour grafts.

Congenital midline cervical cleft: a practical approach to Z-plasty closure.

A congenital midline cervical cleft (CMCC) is a rare developmental abnormality with several common features of variable severity: a midline defect of anterior neck skin, a superior nipple-like skin projection, and a subcutaneous fibrous cord. Congenital midline cervical clefts have important functional and cosmetic implications as cicatrical contracture with subsequent deformity may result without early surgical intervention. Treatment involves excision of all abnormal tissue, and reconstruction with Z-plasty techniques is favored because linear closure results in hypertrophic scarring and recurrent contracture. Z-plasty allows broken-line closure, reorientation of the defect in the horizontal plane with re-creation of a cervicomental angle, and most importantly, a lengthening of the anterior neck skin that aids in preventing recurrent contracture. We present our experience managing a congenital cervical midline cleft in a 3-month-old patient and describe a simple technique for planning the ideal Z-plasty closure. No simple description for planning the ideal closure for this defect could be found in the otolaryngology literature.

Sensitivity and specificity of intraoperative recurrent laryngeal nerve stimulation in predicting postoperative nerve paralysis.

Bilateral recurrent laryngeal nerve (RLN) paralysis after thyroidectomy is infrequent, but serious when it occurs. Intraoperative knowledge of the status of the nerve after dissection could potentially provide the surgeon with important decision-making information. The current study examines the sensitivity and specificity of intraoperative stimulation of the RLN during thyroid surgery for predicting postoperative RLN deficits. Eighty-one RLNs in 55 patients were identified to be at risk of injury during thyroidectomy or parathyroidectomy performed between January 1998 and February 2000. Intraoperative determination of RLN function was evaluated with a disposable nerve stimulator (Xomed, Jacksonville, Florida) set at 0.5 mA. Injury was assessed by palpating for a contraction of the posterior cricoarytenoid muscle while the stimulus was applied. Postoperative assessment of RLN integrity was determined by using indirect or direct laryngoscopy to visualize vocal fold mobility. Nine RLNs failed to elicit a posterior cricoarytenoid contraction after nerve stimulation, and 4 RLNs were determined to be deficient in the postoperative evaluation. The calculated sensitivity and specificity were 75% and 92.2% with a positive predictive value of 33.3% and negative predictive value of 98.6%. The RLN injury rate was 4.94%. We conclude that intraoperative RLN stimulation is a relatively safe and useful method of determining what RLN function will be after thyroid or parathyroid surgery.

Rhinologic pharmacotherapy in rhinoplasty.

Rhinoplasty surgeons inevitably encounter therapeutic considerations in managing their patients, and a thorough understanding of nasal function, as well as of disorders of the nose and sinuses, is requisite for positive clinical outcomes. Patients suffering from allergic rhinitis are not precluded from undergoing rhinoplasty, whereas other disease processes may warrant an otolaryngologic evaluation before proceeding with surgery. A thorough medical history and examination elucidate sinonasal disease conditions that may not improve after septorhinoplasty but potentially could respond to pharmacologic therapy.

Use of the ultrasonic bone aspirator for lateral osteotomies in rhinoplasty.

UNLABELLED: There remains considerable debate over the optimal method and approach to performing lateral osteotomies. Current methods rely on mechanical energy for performance of osteotomies, which can lead to soft-tissue injury and/or disruption of the bony or cartilaginous framework. The authors report the novel use of an ultrasonic bone aspirator device for performance of lateral osteotomies in rhinoplasty. The authors have found this technology to be safe and effective in a series of five consecutive patients. The main benefits of the device include avoidance of soft-tissue/mucosal injury, minimal bleeding/bruising, and the ability to avoid mechanical force to create bony cuts, which can destabilize the bony and/or cartilaginous construct of the nose. Being able to minimize tissue trauma with its associated morbidity while maintaining efficacy makes the ultrasonic bone aspirator an attractive option for lateral osteotomies in rhinoplasty that warrants further investigation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Secondary rhinoplasty and the use of autogenous rib cartilage grafts.

Postoperative rhinoplasty deformities--such as displacement or distortion of anatomic structures, inadequate surgery resulting in under-resection of the nasal framework, or over-resection caused by overzealous surgery--require a secondary rhinoplasty. Success in secondary rhinoplasty, therefore, relies on an accurate clinical diagnosis and analysis of the nasal deformities, a thorough operative plan to address each abnormality, and a meticulous surgical technique. Septal cartilage is the grafting material of choice for rhinoplasty; however, auricular cartilage and rib cartilage are used in secondary rhinoplasty. This article discusses the steps involved in the external approach to secondary rhinoplasty.

Prevention and management of rhinoplasty complications.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify potential hemorrhagic, infectious, traumatic, functional, or aesthetic complications arising from rhinoplasty. 2. Gain a better understanding of the prevention of these complications. 3. Have a thorough knowledge of the principles of postoperative management of these complications, so as to minimize their deleterious effects and preserve aesthetic outcomes in rhinoplasty. SUMMARY: Meticulous attention to detail in the operating room and in the postoperative period is paramount to achieving success in rhinoplasty. Nevertheless, both complications and suboptimal results do occur, even for experienced surgeons.

Dorsal augmentation with autogenous rib cartilage.

Reconstruction of the nasal osseocartilaginous framework is the foundation of successful primary and secondary rhinoplasty. When adequate septal cartilage is unavailable, the rib provides the most abundant source of cartilage for graft fabrication and is the most reliable when structural support is needed. We present the senior author's (J.P.G.) experience and evolution of techniques of dorsal augmentation with autogenous rib cartilage grafts with internal K-wire stabilization in rhinoplasty.

Management of intraoperative fractures of the nasal septal "L-strut": percutaneous Kirschner wire fixation.

BACKGROUND: The area where the septal cartilage joins the perpendicular plate of the ethmoid is a vulnerable region where overresection or disruption during rhinoplasty causes a loss of support and potential collapse of the nasal dorsum, leading to a saddle-nose deformity. Previously described methods of repair involve suture techniques that are often inadequate to restore septal stability. The authors present the senior author's (J. P. G.) experience in managing intraoperative fractures of the septal "L-strut," describe a classification system for the types of dorsal septal L-strut fractures, and present a new method of treatment using percutaneous Kirschner wire fixation. METHODS: The authors conducted a retrospective review of 1372 primary and secondary rhinoplasties performed by the senior author. A classification system was developed to describe the type and location of dorsal septal L-strut fractures. Each patient was treated with immediate restabilization of the fractured dorsal septal L-strut with dorsal spreader grafts, percutaneous Kirschner wire fixation, or a combination of both methods. RESULTS: Seventeen patients sustained an intraoperative fracture of the septal L-strut with an overall incidence of 1.2 percent. Complications included minor dorsal deviation and inadequate reduction/moderate dorsal depression in three patients requiring revision surgery to correct the dorsal deformities. CONCLUSIONS: An intraoperative fracture of the septal L-strut is a rare but unfortunate occurrence during rhinoplasty. Although technically difficult to perform, the percutaneous Kirschner wire fixation technique with or without spreader grafts is a novel and effective approach to this complication.

Frequently used grafts in rhinoplasty: nomenclature and analysis.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Accurately name the most frequently used grafts in primary and secondary rhinoplasty. 2. Describe the precise anatomical position of each graft. 3. Discuss the clinical indications of each graft. SUMMARY: In this article, the authors present the grafting techniques most commonly used to sculpt the nasal framework in primary and secondary rhinoplasty. The grafts are described in terms of their nomenclature, anatomical location, and clinical indications, presenting a simple and easy-to-reference guide for both beginners and expert surgeons.