Refinements in Saddle Nose Reconstruction.

Saddle nose correction remains a challenging procedure for rhinoplasty surgeons due to both aesthetic and functional issues. The most common causes of saddle nose are nasal trauma and prior septal surgery, and a defective relationship between the caudal septum and the anterior septal spine is the principal postoperative pathology. The authors propose their own classification system for saddle nose with one new category and several approaches to deal with this condition in accordance with the level of severity. They strongly advocate major septal reconstruction for most cases of saddle nose, either by placing extended spreader grafts, caudal extension grafts, or a new extracorporeally made L strut. For extreme cases, integrated dorsal implant with columellar strut can successfully bypass the saddled nasal dorsum without dissecting the septal mucoperichondrial pocket and achieve adequate dorsal height. Further dorsal augmentation can be achieved by applying side/gap grafts or dorsal onlay grafts in different forms. In cases with retracted columella, a premaxillary plumping graft is another useful technique. Finally, in autoimmune-related saddling patients, the evidence indicates that their aesthetic problems can be managed safely with surgery as long as the disease is well under control.

Nasal Base Retraction: A Treatment Algorithm.

BACKGROUND: Nasal base retraction results from cephalic malposition of the alar base in the vertical plane, which causes disharmony of the alar base with the rest of the nose structures. Correcting nasal base retraction is very important for improved aesthetic outcomes; however, there is a limited body of literature about this deformity and its treatment. OBJECTIVES: Create a nasal base retraction treatment algorithm based on a severity classification system. METHODS: This is a retrospective case review study of 53 patients who underwent rhinoplasty with correction of alar base retraction by the senior author (S.T.). The minimum follow-up time was 6 months. Levator labii alaque nasi muscle dissection or alar base release with or without a rim graft on the effected side were performed based on the severity of the alar base retraction. Aesthetic results were assessed with objective grading of preoperative and postoperative patient photographs by two independent plastic surgeons. Functional improvement was assessed with patient self-evaluations of nasal patency. Also, a rhinoplasty outcomes evaluation (ROE) questionnaire was distributed to patients. RESULTS: Comparison of preoperative and postoperative photographs demonstrated that nasal base asymmetry was significantly improved in all cases, and 85% of the patients had complete symmetry. Nasal obstruction was also significantly reduced after surgery (P < 0.001). The majority of patients reported satisfaction (92.5%), with an ROE total score greater than or equal to 20. CONCLUSIONS: New techniques and a treatment algorithm for correcting nasal base retraction deformities that will help rhinoplasty surgeons obtain aesthetically and functionally pleasing outcomes for patients.

[The morphological and clinical aspects of the curvature of the nasal septum]. / Morfologicheskie i klinicheskie aspekty iskrivleniia peregorodki nosa.

The curvature of the nasal septum (NS) is one of the most widespread deformations of the facial skeleton. The objective of the present study was to substantiate the principles of and develop the rationale for the surgical correction and conservative treatment of this condition based on the morphological features of various types of deflection of the nasal septum. We have undertaken the morphological analysis of the osseous and cartilaginous structures determining the type and the shape of the curvature of the nasal septum together with the clinical analysis of different morphological variants of the deflection of the nasal septum making use of the R. Mladina classification. Type I-IV vertical deflections are regarded as the acquired deformities whereas type II deviations can just as well be congenital malformations. Types V and VI deflections can be a consequence of the birth injury resulting in the displacement of the nasal structures and leading to the curvature of the nasal septum. The authors describe the defects in the anatomical structures adjoining the nasal cavity associated with various types of the deflection of the nasal septum that the surgeons should take into account when planning and performing septoplasty.

Seven fundamental procedures for definitive correction of unilateral secondary cleft lip nasal deformity in soft tissue aspects.

PURPOSE: It is accepted that patients who undergo appropriate primary repair for cleft lip will have secondary deformities. Because these deformities are caused by complex and diverse patterns, the deformities were categorized to provide a standardized treatment for each category. PATIENTS AND METHODS: Pathologic characteristics of 1,170 patients were classified into 7 categories. Corrections were performed using 7 fundamental procedures corresponding to the surgical resolution of each deformity: 1) transposition of the caudal septum; 2) release of the septal-cartilaginous junction; 3) medial crus elevation; 4) lateral crus elevation; 5) release of the orbicularis oris muscle from the lip elevators; 6) anchoring of the orbicularis oris muscle to the anterior nasal spine; and 7) philtral column formation. A satisfaction survey was performed to evaluate the overall outcomes in 171 patients and an anthropometric analysis was performed in 38 patients. RESULTS: Satisfactory scores obtained through postoperative follow-up were higher than preoperative scores, and there was no difference between postoperative scores obtained over the short and long term. All preoperative anthropometric measurements were different from the postoperative measurements, indicating that the fundamental procedure achieved effective outcomes. CONCLUSIONS: These proposed 7 fundamental procedures can be used as guidelines that can always be applied for the correction of any secondary cleft lip nasal deformity to obtain ideal treatment outcomes.

Surgical approach to nasal valves and the midvault in patients with a crooked nose.

Management of the crooked nose and valve obstruction is a challenge for even the most experienced rhinoplasty surgeon. Optimal treatment to restore a functional airway and improve cosmesis requires addressing the nasal valves. Several different techniques are available to guide the rhinoplasty surgeon to achieve the best outcome.

The crooked nasal tip.

Successful treatment of the crooked nasal tip includes proper analysis and assessment, employment of the proper techniques, reaching ideal tip dynamics, and close follow-up. Both the caudal septum and the nasal tip cartilages must be addressed. When executed properly, satisfaction should be high for both the patient and the surgeon.

Is Computed Tomography Imaging of Deviated Nasal Septum Justified for Obstruction Confirmation?

Third-party payers request objective confirmation of the nasal septum deviation (NSD) severity by computed tomography (CT) before authorizing financial support for septoplasty. Previous studies have provided contradictory results related to the link between obstruction severity and CT-measured angle of the NSD. The aim of this study was to investigate whether the diverse CT morphology of NSDs (including previously neglected types and shapes) could predict obstruction severity. The study included 225 patients with NSD. The CT morphology of the septum was analyzed using 5 different classifications of NSD that are commonly used in the clinical practice and research. The angle of NSD was also measured. Nasal obstruction was assessed by the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire. A relationship between CT morphology and the angle of the NSD and NOSE scores was analyzed using appropriate regression models. Patients with NSDs located in the anterior part of the septum always have some degree of nasal obstruction, while those with posterior NSDs did not necessarily report obstruction symptoms no matter how complicated NSD they have. Regression analysis did not reveal any causal relationship between NOSE scores and CT morphology and the angle of NSD. The presence of spurs and whether they divide nasal passages have no statistically significant predictive effect on the obstruction severity. The CT morphology and the angle of the NSD could not predict severity of the nasal obstruction. Requesting CT examination just to objectively confirm nasal obstruction is not justified.

Classification of the deviated nose and its treatment.

OBJECTIVE: To present a simplified classification of the deviated nose and the associated treatment outcome. DESIGN: Retrospective analysis. SETTING: Tertiary care rhinology clinic. PATIENTS: Seventy-five individuals (49 males and 26 females) who underwent rhinoplasty for a deviated nose with minimum follow-up of 36 months. MAIN OUTCOME MEASURES: Depending on the orientation of 2 horizontal subunits (the bony pyramid and the cartilaginous vault) with respect to the facial midline, the nasal deviations are classified into 5 types: I, a straight tilted bony pyramid with a straight tilted cartilaginous vault in the opposite direction; II, a straight tilted bony pyramid with a concavely or convexly bent cartilaginous vault; III, a straight bony pyramid with a tilted cartilaginous vault; IV, a straight bony pyramid with a bent cartilaginous vault, and V, a straight tilted bony pyramid and a tilted cartilaginous dorsum in the same direction. RESULTS: Deformities of types I through V occurred in 24 (32%), 19 (25%), 19 (25%), 7 (9%), and 6 (8%) patients, respectively, in whom 1, 3, 2, 1, and 1 unsuccessful outcomes were found. Four of the 8 failed cases had been approached endonasally. CONCLUSION: The proposed classification for the deviated nose could serve as a valuable adjunct in the treatment of these patients.

A new classification of septal deviations.

STATEMENT OF PROBLEM: Existing nomenclatures of septal deviation deal with the deformation of the nasal septum exclusively and are rarely used in daily clinical work. The aim of this study was to develop a classification of septal deviations based upon the anatomical structures of the nasal septum and common clinical concepts. METHODS OF STUDY: We included patients undergoing septoplasty alone or in combination with rhinoplasty or functional endonasal sinus surgery by reason of septal deviation. Immediately after surgery, the surgeon recorded intraoperative findings of the nasal septum and the nasal turbinates in a data sheet and a standardized drawing for every patient. MAIN RESULTS: Data from 1088 patients were analyzed. Six types of septal deviations were identified. This new classification of septal deviations was developed with special regard to clinical anatomical findings. Leading as well as concomitant pathological findings were assigned to the six types of septal deviation. The frequencies of occurrence of hyperplasia of the inferior turbinate and concha bullosa of the middle turbinate were specified. PRINCIPAL CONCLUSION: The systematic assessment of relevant structures may help to develop improved surgical strategies. Furthermore, the systematic teaching of young surgeons to perform septal surgery may be facilitated.

The Saddle Deformity: Camouflage and Reconstruction.

This article presents a comprehensive review of past and present modalities in the surgical management of saddle nose deformities. Various surgical techniques, including allograft materials, are systematically reviewed. The senior author's surgical experience and current management approach are highlighted.

Saddle nose deformity: A new classification and treatment.

Treatment of saddle noses challenges the surgeon to provide esthetic form and functional improvement despite the presence of a limited amount of tissue to work with. The previous emphasis on alloplastic materials was a testament not only to the poor results obtained with autogenous tissues but also the unwarranted promise of the "miracles of modern chemistry." Only in the last 5 years have multiple surgeons begun to achieve outstanding results using autogenous tissues. It is hoped that this article will encourage younger surgeons to build on this foundation and provide hope to a group of patients who deserve our best efforts. Saddle nose and cleft lip nose deformity warrant a commitment to surgical excellence.

Evaluation of nasal mucociliary transport rate according to nasal septum deviation type.

BACKGROUND: Nasal septum deviation (NSD) may affect mucociliary activity (MCA) to varying degrees, depending upon the severity of the deviation. We used rhinoscintigraphy to determine the impact of the various NSD types on MCA. METHODS: A recent classification describing 6 different forms of NSD was used to standardize the study. Forty-eight subjects were enrolled. Eight patients for each form of NSD were accrued for further study. Rhinoscintigraphy was performed using technetium 99m macroaggregated albumin ((99m) Tc-MAA) before and 3 months after surgery. Nasal mucociliary transport rate (NMTR), the half-time of (99m) Tc-MAA activity, and clearance rate over a 20-minute period were compared between groups. RESULTS: Preoperative NMTR and clearance rates were significantly lower and half-time was significantly longer in types 4 and 6 than in the other groups. Although the postoperative NMTR and clearance rates increased compared with preoperative values in all groups, the increase was significant only in types 2, 4, and 6. The postoperative half-time increased significantly compared with the preoperative values in types 2, 4, and 6. The postoperative rhinoscintigraphy evaluation revealed no significant differences among groups in NMTR, half-time, or clearance rate. CONCLUSION: NSD types 4 and 6 had lower preoperative NMTR and clearance rates and a longer half-time compared with the other groups. However, the postoperative values of these parameters were not significantly different among groups. Our results indicate that NSD types 4 and 6 had the greatest impact on MCA, suggesting that these patients may receive the maximum benefit from septoplasty.

Classification of nasal defects: a practical guide for reconstruction.

Nasal defects are among the most complicated problems frequently facing the otolaryngologists--head and neck surgeon. The complex role of the nasal structure and its anatomy makes a practical guide for reconstruction particularly attractive. The nose, as a unique facial component, must ideally perform important airway functions, while also having an acceptable appearance. A range of reconstructive problems from simple defects to total nasal loss is addressed.

Analysis of nasal and labial deformities in cleft lip, alveolus and palate patients by a new rating scale: preliminary report.

INTRODUCTION: In this study the nasal deformities in patients with cleft lip, alveolus and palate (CLAP) were analysed and the relevant role of the perinasal-perioral muscular balance, and the inborn dislocation of the alar cartilages is presented. PATIENTS AND METHODS: 50 CLAP patients were analysed in whom 29 primary cheiloplasties, 12 lip revisions and 9 rhinoplasties were performed. The lip repair was done by a modification of Millard's technique, the nose by either a closed or open-sky rhinoplasty. The severity of the cleft appearance was evaluated pre- and postoperatively, according to a pre-agreed visual rating scale. There were 4 degrees of severity of the deformity preoperatively (mild, moderate, severe and very severe), and postoperatively 5 categories of outcome (excellent, very good, good, satisfactory and poor) depending on the scores obtained by summing up the points corresponding to different types of deformity. This scale is closely related to the American Cleft Palate classification of clefts. RESULTS: 17 excellent, 4 very good, 2 good, 5 satisfactory and 1 poor result were obtained in the group of primary cheiloplasty. Eight excellent, 4 very good results were obtained by the lip revisions. Seven excellent and 2 satisfactory results were obtained following rhinoplasty. CONCLUSIONS: During the primary lip repair, it is important to correct the abnormal position of ala nasi, the nasal floor and the base of the columella. When correct insertion of m. transversus nasi to the nasal spine is achieved and a good repair of m. orbicularis oris, symmetry of the alae and normal growth of lip and columella was obtained even in most severe bilateral cases. In cases of diastasis of the orbicularis and transversus nasi muscles, in combination with other soft tissue deformities or scars, a secondary musculo-periosteal revision is recommended. The defect of the soft tissue triangle of the nose is best corrected via an open rhinoplasty.

The role of maxillar morphology in the development of pathological septal deformities.

As a rule some kinds of nasal septum deformities are more frequently found in subjects whose maxilla has more or less stressed morphological irregularities than in those with a normally shaped maxilla. The subjects with asymmetry between the nasal floor levels (the right and left side) show heavier septal damages than others. It means that a regularly shaped maxilla as well as a symmetric nasal floor serve like a fuse against the more severe deformations after nasal trauma. In this paper we have made a classification of the septal pathological deformities.

[The deviated nose. Classification and treatment. Apropos of 100 cases]. / Les nez déviés. Classification et traitement. A propos de 100 cas.

We present a series of 100 deviated noses treated over 5-year period. A classification into four groups was proposed and used to determine preoperative strategy according to the type of deformation. The main corrective methods were lateral cartilage grafts for C-shaped noses and removal and reinstallation of the nasal cartilage for S-shaped nose and "lay down" noses. The best results were obtained for trauma-induced deformations occurring after puberty. Lay-down nose were more difficult to treat than C- and S-shaped noses. Good results can be expected in 80% of the cases. Good nasal flow was obtained in 90% of the patients and secondary surgery was successful in the other 10%.

[Congenital malformations of nose and paranasal sinuses]. / Vrozhdennye poroki i anomalii razvitiia nosa i okolonosovykh pazukh.

410 patients with malformations of the external ear or nasal cavity were examined. Basing on this evidence, clinical and diagnostic aspects of agenesias, hypogenesias, hypergenesia, dysgenesia, persistence and dystopias of the nose and intranasal structures are analyzed. Both severe and "minor" anomalies are considered. Endoscopic diagnosis of the malformations is described.

[The classification of combined deformities of the nose]. / O klassifikatsii kombinirovannykh deformatsii nosa.

A classification of deformations of the nose is proposed. All deformations are classified into 5 degrees: I) deformations involving one compartment of the nose, II) two compartments, III) three compartments, IV and V) combined deformations involving more than 4 compartments. This classification helps the physician to be better oriented in the great variety of combined deformations of the nose and permits a more accurate planning of the steps of surgery. This classification is not a final or exhausting, it is merely an attempt to present a scheme of the great variety of combined deformations of the nose and attract the attention of specialists to development of better classifications needed by practical medicine.