Reverse nasal SMAS-perichondrium flap to avoid supratip deformity in rhinoplasty.

BACKGROUND: Supratip deformity is an iatrogenic convexity that occurs cephalically to the nasal tip. This is also known as "parrot beak" deformity and causes an unnatural appearance of the nose. In the literature there are several explanations of the mechanism of the deformity and methods to correct it. One of the most accepted theories about the cause of supratip deformity is overresection of the caudal dorsum. Healing soft tissues fill in the gap created between the septum and the tip of the lower lateral cartilages, leading to fullness in the supratip area. The lower third and basically distal third of the middle third of the nose include several muscle groups, ligamentous structures, and perichondrium as the subcutaneous soft tissues. METHODS: With the idea of elevating a reverse-based flap basically from the lower third and the lower third of the middle third of the nose, including the perichondrium and SMAS tissue, we aimed to reduce this gap, which has the potential to accumulate soft tissues that cause supratip fullness. Between December 2008 and July 2010, the reverse nasal SMAS-perichondrium flap was used in 42 primary rhinoplasty patients. RESULTS: This flap was used in 42 patients. Follow-up ranged from 3 to 18 months. No early or late complications were noted, such as infection, excessive bleeding, or extended edema. Minor revisions were performed in only two patients with the aim of achieving a smoother nasal dorsum. CONCLUSIONS: The reverse nasal SMAS-perichondrium flap is a new flap. The results presented here are not long term; however, the preliminary results are promising. The flap should be avoided in cases of thin skin, or at least be used with caution, whereas in thick skin cases it is very safe. Further studies in larger groups are required to better define the advantages and disadvantages of this flap.

Excision and "transcutaneous" lift in patients with neurofibromatosis of the fronto-temporo-orbital and auricular regions.

Neurofibromatosis (NF) type 1 (von Recklinghausen disease) involves the face in up to 4% of the cases. Patients present with varying degrees of disfigurement according to the extent and location of the tumor. Many surgeons prefer multiple serial excisions, as it is almost impossible to remove the entire tumor without major extirpative surgery. However, because the "debulkings" are usually not accompanied by durable lift procedures, the skin sags again because of the gravitational effect on the remaining tumor. In a series of 7 patients with NF of the frontal, temporal, facial, and cervical areas and the auricle, a lift procedure was performed after functional debulking of the tumor. The lift sutures, which passed transcutaneously, supported and fixed the predetermined areas on the skin or the ear cartilage to the periosteum of the calvarium. All the patients previously had multiple debulking surgeries without any lift procedures, which resulted in resagging of the facial elements within 3 months of surgery. The transcutaneous lift was durable up to 1 year in preventing resagging. After 1 year, because of the presence of disease, there was a slow relapse in the amount of sagging in the temporal and frontal areas, but not in the auricle. In 3 patients, re-excision of the disease and repeat lift procedure using the same technique were performed after 1 year. All were satisfied with the results and stated that the period without sagging lasted longer compared with their prior surgeries. The patients indicated that they were able to socialize more often and without being overly concerned with their appearance. The patients with NF type 1 undergo many operations during their lifetime. Many of these procedures are debulking procedures to reduce the size of the diseased tissues. These procedures are not aimed to completely eliminate the disease, but rather to improve function and appearance. When these debulking procedures are combined with durable lifting procedures, the results are longer lasting with improved quality of life.