Anatomy of the nasal latero-lateral cartilage articulation: a micro-MRI study in human specimens.

PURPOSE: To study the anatomy of the latero-lateral joint (LLJ) between the upper lateral (ULC) and lower lateral (LLC) crus of the nasal cartilages, usually described as a scroll articulation. METHODOLOGY: Six nasal pyramids were taken in monobloc from fresh cadavers and imaged on micro-MRI with 0.4 mm slice thickness. Images were jointly interpreted by two head and neck radiologists and one surgeon. The junction between the ULC and LLC, the presence of ligaments and of sesamoid or accessory cartilages were assessed. RESULTS: Eight LLJs could be analyzed, with four types of junctions: hook-shaped cephalic border of the LLC turned towards the nasal fossa and linear caudal border of the ULC (n = 3), hook-shaped caudal border of the ULC and linear cephalic border of the LLC lateral crus (n = 1), hook-shaped border of both cartilaginous edges with clinging (n = 1) (scroll articulation) or without clinging (n = 3). No ligament or sesamoid cartilage was found, but posterior accessory cartilages were seen in 75% of the cases. CONCLUSION: The classical scroll articulation of the LLJ has been observed in only 1/8 cases on micro-MRI images. The anatomy of the LLJ could explain the surgical difficulty in raising the tip of the nose in some patients and not in others.

Rhinogoniometer: Validation of an Instrument for Rhinoplasty.

SUMMARY: The position of the lower lateral cartilages is directly related to good nasal functionality. When these cartilages exhibit cephalic malposition, the angle of divergence between cartilages is usually less than 60 degrees, which can cause external nasal valve insufficiency. The objective of this study was to validate the rhinogoniometer, an innovative surgical instrument that allows for diagnosing the position of this cartilage intraoperatively. In the intraoperative period, the angle of divergence, which is the angle formed between the two lateral branches of the lower lateral cartilages, was measured in 31 primary rhinoplasty patients. The rhinogoniometer measurement was compared with that of the computerized analysis, and the reproducibility of measurements with the rhinogoniometer between two different surgeons was determined. When comparing the values obtained by the two methods, a significant difference was found (p = 0.034). On average, the angles measured by the rhinogoniometer were 3.7 degrees smaller than the measurements made by the software. It was observed that when the angles measured by both methods were above 75 degrees, the differences between the two measurements were higher (p = 0.022). However, for angles up to 75 degrees, the measurement using the rhinogoniometer was, on average, 0.79 degrees higher than the measurement taken by the software. When the difference in angles obtained by the two methods between different surgeons was evaluated, there was a significant difference (p < 0.023). In conclusion, at angles up to 75 degrees, the rhinogoniometer showed a negligible difference of 0.79 degrees higher than the measurement obtained via software. Measurements with the rhinogoniometer were also shown to be reproducible with different surgeons.

Zone-Dependent Architecture and Biochemical Composition of Decellularized Porcine Nasal Cartilage Modulate the Activity of Adipose Tissue-Derived Stem Cells in Cartilage Regeneration.

Previous anatomical studies have shown different functional zones in human nasal septal cartilage (NC). These zones differ in respect to histological architecture and biochemical composition. The aim of this study was to investigate the influence of these zones on the fate of stem cells from a regenerative perspective. Therefore, decellularized porcine septal cartilage was prepared and subjected to histological assessment to demonstrate its equivalence to human cartilage. Decellularized porcine NC (DPNC) exposed distinct surfaces depending on two different histological zones: the outer surface (OS), which is equivalent to the superficial zone, and the inner surface (IS), which is equivalent to the central zone. Human adipose tissue-derived stem cells (ASCs) were isolated from the abdominal fat tissue of five female patients and were seeded on the IS and OS of DPNC, respectively. Cell seeding efficiency (CSE), vitality, proliferation, migration, the production of sulfated glycosaminoglycans (sGAG) and chondrogenic differentiation capacity were evaluated by histological staining (DAPI, Phalloidin, Live-Dead), biochemical assays (alamarBlue®, PicoGreen®, DMMB) and the quantification of gene expression (qPCR). Results show that cell vitality and CSE were not influenced by DPNC zones. ASCs, however, showed a significantly higher proliferation and elevated expression of early chondrogenic differentiation, as well as fibrocartilage markers, on the OS. On the contrary, there was a significantly higher upregulation of hypertrophy marker MMP13 (p < 0.0001) and GAG production (p = 0.0105) on the IS, whereas cell invasion into the three-dimensional DPNC was higher in comparison to the OS. We conclude that the zonal-dependent distinct architecture and composition of NC modulates activities of ASCs seeded on DPNC. These findings might be used for engineering of cartilage substitutes needed in facial reconstructive surgery that yield an equivalent histological and functional structure, such as native NC.

The Caucasian Hump: Radiologic Study of the Osteocartilaginous Vault versus Surface Anatomy. Clinical Implications in Structured and Preservation Rhinoplasty.

BACKGROUND: The relation between the osteocartilaginous nasal vault and nasal hump characteristics has not been fully investigated. METHODS: Measurements were collected from computed tomographic nasal scans in the midsagittal plane in adult Caucasian patients seeking rhinoplasty because of nasal hump from January of 2015 to December of 2018. Measurements were compared to those of sex- and age-matched patients not seeking rhinoplasty (control group). Patients with other significant nasal deformities were excluded. The correlations between nasal hump length, height, and osteocartilaginous nasal vault measurements were assessed. Distances from the beginning of the nasal hump to the kyphion and ethmoidal points were measured as well. The location of the nasal hump apex in relation to the keystone area structures was detailed. RESULTS: The study included 134 Caucasian patients, with 67 presenting nasal hump. The mean patient age was 32.9 years and 69.6 percent were female patients. Nasal hump measured a mean 17 ± 2.7 mm in length and 1.8 mm (range, 1.1 to 3.8 mm) in height. Nasal hump length correlated with nose length and nasal bone length. Nasal hump height correlated with nose length and the angle over the kyphion. In 97 percent of patients, the nasal hump began caudal to the ethmoidal point, and in all patients, the kyphion was underneath the nasal hump. The nasal hump is not a symmetric structure and, in all patients, its apex was situated above the septal cartilage. CONCLUSIONS: The nasal hump characteristics are mainly attributable to the septal cartilage, and this should be the cornerstone of any dorsal hump reduction strategy. The caudal aspect of the nasal bones contributes to the nasal hump, whereas the posterior ethmoidal plate rarely does.

Middle Vault Changes After Humpectomy by Spare Roof Technique Versus Component Dorsal Hump Reduction.

Objectives: To compare the effect of two different humpectomy techniques in the internal nasal valve (INV) angle in human anatomic specimens. Methods: Seven human anatomic specimens (14 heminoses) were included. A strip of subdorsal septal cartilage was removed and, in each nose, the right side of the middle roof lied intact over and was sutured to the septal cartilage (spare roof technique [SRT]), whereas in the left side the upper lateral cartilage was folded and sutured to the septal cartilage (component dorsal hump reduction [CDHR]). The INV angle was measured pre- and postoperatively. Results: Mean age of the specimens was 69.86 (60-80) years. Five were female. CDHR resulted in a mean change of +1.71 ± 3.12° (p = 0.197), +0.62 ± 6.89° (p = 0.817) and +6.97 ± 6.84° (p = 0.036) after resection of 2, 4, and 6 mm of septal cartilage, respectively. SRT resulted in a mean change of +1.27 ± 2.37° (p = 0.207), +6.89 ± 1.19° (p < 0.001), and +12.55 ± 1.79° (p < 0.001) after resection of 2, 4, and 6 mm of septal cartilage, respectively. In SRT, the amount of septal cartilage resection presented a significant correlation with change in INV angle (r = 0.813, p < 0.001). Conclusions: In this human anatomic study, SRT significantly increased INV angle.

Finite Element Analysis of the Septal Cartilage L-Strut.

Importance: Septoplasty is one of the most commonly performed operations in the head and neck. However, the reasons for septoplasty failure and the additional stress of performing a chondrotomy on the septal cartilage are not well understood. Design, Setting, and Participants: A finite element model of the nasal septum was created using a microcomputed tomography scan of the nasoseptal complex that was reconstructed into a three-dimensional model in silico. Testing included four common chondrotomy designs: traditional L-strut, double-cornered chondrotomy (DCC), curved L-strut, and the C-curve. Tip displacement was applied in a vector parallel to the caudal strut to simulate nasal tip palpation. Main Outcomes and Measures: With finite element analysis, the maximum principal stress (MPS), von Mises stress (VMS), harvested cartilage volume, and surface area were recorded. Results: The highest MPS for the L-strut, DCC, curved L-strut, and C-curve was identified at the corner of the chondrotomy. The MPS at the corner of the chondrotomy was reduced 44% when comparing the C-curve with the traditional L-strut. The VMS patterns showed compressive stress along the caudal septum in all models, but at the corner, the stresses were highest in the chondrotomies designed with sharp-angled corners. The VMS showed a 76% decrease when comparing the C-curve with the traditional L-strut. The stress across the anterior septal angle is also higher in models with sharp-angled corners. Cartilage harvest volumetric and surface area assessments did not show meaningful differences between shapes. Conclusions and Relevance: The highest area of stress is near the transition of the dorsal to caudal septum in all models. Stresses are relatively higher in chondrotomy shapes that contain sharp-angled corners. The relative reduction in MPS and VMS utilizing a C-curve instead of an L-strut may decrease the likelihood that the septum will deform or fail in this region. The volume and surface area of the C-curve are similar to that of the L-strut technique. Avoiding sharp-angled corners reduces the stresses at the corner of the chondrotomy and across the anterior septal angle. Using a C-curve may be an improved septoplasty design.

North American survey and systematic review on caudal Septoplasty.

BACKGROUND: Surgical correction of caudal septal deviation is a technically challenging step of functional rhinoplasty. Multiple surgical techniques have been described in the literature but comparing the efficacy of each in relieving obstruction presents a challenge. Outcome measures are necessary to adequately compare techniques. This study aims to describe the current caudal septoplasty techniques of Otolaryngologists and Facial plastic and reconstructive surgeons (FPRS), as well as their use of outcome measures, and to compare these practices with surgical trends described in the literature. METHODS: An online survey was sent to three Otolaryngology and FPRS associations in Canada and the United States. A systematic review was conducted on SCOPUS and PubMed to classify the caudal septoplasty techniques described in the literature and the outcome measurement tools used. RESULTS: Our survey identified that caudal septoplasty is more commonly performed by surgeons with an FPRS training background. The most common techniques were the swinging door technique (69.5%), extracorporeal septoplasy (46.7%), cartilage scoring (45.3%), and splinting with bone (25.4%). Despite using a vast array of surgical techniques, North American physicians rarely rely on standardized outcome assessment tools. Patient reported outcome measures (PROMs) are used almost twice as frequently in the literature as they are by surgeons in their clinical practice. CONCLUSION: We recommend that future studies of caudal septoplasty include an assessment of both form and function using a validated PROM such as the Standardized Cosmesis and Health Nasal Outcomes Survey.

The Keystone, Scroll Complex, and Interdomal Area of the Nose: Histologic and Anatomical Observations.

Comprehensive knowledge of nasal anatomy is essential for obtaining aesthetically and functionally pleasing results in rhinoplasty. In this study, the authors described the anatomy, histology, and clinical relevance of the interdomal region, keystone, and scroll complex. The current study examined these areas in 26 fresh cadaver heads. All cadavers were fresh, and no conservation or freezing processes were applied. All dissections were performed by the first author. It was determined that the structure that connected the middle crura in the interdomal region actually came together in the transverse plane and contained abundant capillaries within. It was observed that chondroblasts with high regenerative potential were present in the keystone area, and there was very tight attachment between periosteum and perichondrium. The scroll complex was found to be more flexible and thin and had fewer regenerative cells compared to the keystone region. With its unique anatomy and histology, the keystone acts as a transition area between the flexible and fixed units of the nose. The scroll complex should be taken into consideration during rhinoplasty because of its effects on fixation of the skin in the lateral supratip area and functional effects on internal and external nasal valves. The interdomal ligament, in contrast, acts as a transition between both middle crura rather than a real ligament.

Decision-Making in Middle Vault Reconstruction following Dorsal Hump Reduction in Primary Rhinoplasty.

BACKGROUND: Dorsal hump reduction during open rhinoplasty disrupts the continuity between the upper lateral cartilages and the dorsal septum. Options to reconstitute the midvault include primary closure of the upper lateral cartilages to the dorsal aspect of the septum, placement of spreader grafts, and creation of spreader flaps. The authors sought to clarify from highly experienced rhinoplasty surgeons their decision-making rationale for midvault reconstruction, distilling down the group consensus into algorithmic guidelines. METHODS: A panel of internationally recognized rhinoplasty surgeons participated in a two-part organized communication method. An introductory summit consisted of open discussions on various topics in midvault reconstruction. The summit transcription was analyzed by thematic content analysis to develop a survey encompassing clinical scenarios for primary rhinoplasty, which was then individually administered to each panelist. Data gathered from both parts were used to generate technical guidelines and a decision-making algorithm. RESULTS: The panelists identified the following anatomical features as pertinent to their selection of midvault reconstruction method: size of the dorsal hump reduction, width of the midvault relative to the upper vault, presence of dorsal angulation, and presence of nasal obstructive symptoms. Individual panelist preference was gathered from the 24-scenario survey divided into either cosmetic or functional rhinoplasty cases. CONCLUSIONS: Management of the midvault after dorsal hump reduction is important to establish proper aesthetic relationships and to provide functional integrity of the internal valve. Our authors present an algorithmic approach to decision-making based on the systematic analysis practiced by senior rhinoplasty surgeons.

Practical Classification of Upper Lateral Cartilage in Middle Vault Asymmetry.

BACKGROUND: Middle vault asymmetry is a common reason for retained postoperative deviations. Although minor deformities can be camouflaged with cartilage, soft-tissue materials, or injectable fillers, comprehensive observation of upper lateral cartilage and subsequent topographic classification in major anatomical anomalies will help surgeons better plan their procedures to obtain better symmetry. METHODS: Photographs of 71 randomly selected primary open rhinoplasty patients were analyzed for anatomical presentation of their upper lateral cartilage. Photographs were taken before and after separation of upper lateral cartilage from the septum. Upper lateral cartilage was classified from class I to class V according to the width of the transverse subunits and curvature of the vertical subunits. RESULTS: The authors observed 142 upper lateral cartilages of 71 rhinoplasty patients. Upper lateral cartilage was classified as follows: class I, 53 cases; class II, three cases; class III, 40 cases; class IV, 36 cases; and class V, 10 cases. CONCLUSIONS: Upper lateral cartilage asymmetry is a common occurrence in rhinoplasty, and the upper lateral cartilage itself may be the source of nasal deviation. The middle vault requires special attention, and establishment of a classification system could enable surgeons to devise an effective plan for correction and prevention of retained postoperative nasal deviation.

Secondary Unilateral Cleft Rhinoplasty Using Natural Curvature of Rib Cartilage as Alar Rim Graft: A Three-Dimensional Evaluation of Long-Term Results.

BACKGROUND: Since 2012, the senior author has incorporated the natural curvature of rib cartilage as an alar rim graft in addition to the diced cartilage technique for unilateral cleft rhinoplasty. The aim of this study is to describe this modification and evaluate its long-term results regarding nasal symmetry using three-dimensional stereophotogrammetric assessment (3dMDface system). METHODS: From 2012 to 2018, 47 consecutive patients that underwent secondary unilateral cleft rhinoplasty were reviewed retrospectively. Sixteen patients with both preoperative and postoperative three-dimensional photographs taken at least 6 months after the operation were included. SimPlant O&O software was used to measure parameters on three-dimensional photographs: nostril heights, nostril widths, nasal dorsum heights, alare width, nostril areas, overlapping nostril area, nasal tip protrusion, nasal length, and nasal height before and after surgery. The ratios between cleft and noncleft sides were calculated. In addition, the overlapping nostril area ratio, tip protrusion-width index, and nasal index were compared before and after surgery. RESULTS: The preoperative nostril height ratio (0.79), nostril width ratio (1.24), and nasal dome height ratio (0.84) between cleft and noncleft sides were significantly improved after surgery to 0.93, 1.06, and 0.97, respectively. The preoperative overlapping nostril area ratio (72.33 percent), nasal tip protrusion-width index (0.48), and nasal index (0.81) also showed significant improvement postoperatively to 83.91 percent, 0.57, and 0.74, respectively. CONCLUSION: This preliminary study supports the use of natural curvature of rib cartilage as alar rim graft in secondary unilateral cleft rhinoplasty, with long-term improvement regarding nasal symmetry and nasal profile. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Postsurgical Alar Retraction: Etiology and Treatment.

The cephalic trim technique is a popular maneuver that often leads to tip deformities, most notably postsurgical alar retraction (PSAR). We advocate using the external rhinoplasty approach to correct PSAR by (1) releasing and repositioning the retracted alar margin, (2) strengthening and immobilizing the central tip complex using a septal extension graft, (3) suspending and longitudinally tightening the mobilized lateral crural remnant by adjusting crural length to match the sidewall span, and (4) providing direct skeletal support to the repositioned alar margin using articulated alar rim grafts. Using this structural treatment paradigm, we have corrected severe PSAR in the preponderance of secondary rhinoplasty cases.

Revisiting the Alar-Columellar Relationship: Classification and Correction.

The alar-columellar relationship has tremendous aesthetic significance in the lower one-third of the nose. Aberrancies in the alar-columellar relationship detract from nasal aesthetics, and are classified into six types: type I, hanging columella; type II, retracted ala; type III, combination of a hanging columella and retracted ala; type IV, hanging ala; type V, retracted columella, and type VI, combination of a hanging ala and retracted columella. This article describes the methods for proper evaluation and diagnosis of aberrancies in the alar-columellar relationship, and current strategies to restore the ideal alar-columellar relationship. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Combined Nasal Osteotomies With Caudal Transverse Osteotomy and Their Effect on Dorsal Geometry.

Background: Congenital, traumatic, or developmental bony vault deformities may require additional interventions rather than classical osteotomies to correct the surface structure or angulations of the nasal bones in rhinoplasty. Objectives: The aim of the study was to determine the effects of the additional osteotomies applied for the correction of the nasal vault asymmetries retrospectively. Methods: Twenty-one patients among 512 primary rhinoplasty cases between 2011 and 2016 with bony vault asymmetries were included in the study. Three patients had bilateral convex, 6 patients had unilateral convex, and 7 patients had unilateral concave surface deformities. Five patients had concave deformity on one side and convex deformity on the other side. Double-layer lateral osteotomies and caudal transverse osteotomies were conducted for the correction of the severe surface anatomy deformities of the nasal bones. The caudal transverse osteotomy was delicately performed with a special osteotome, which was designed to protect inner periosteum and mucosa of the nasal bone, and to prevent uncontrolled fracture formation with thinned edge. Results: Twenty patients (95.2%) had favorable results with restoration of a symmetric bony and cartilaginous nasal vault configuration. None of the bone fragments showed any rotation or malposition. One (4.8%) patient with a crooked nose had suboptimal dorsal geometry without requiring revisional surgery at the level of the cartilaginous nasal vault. Conclusions: The author described the morphology, clinical relevance, and correction methods of the nasal vault and the changes that occur in this area during rhinoplasty in patients with concave, convex, or combined three-dimensional nasal bone deformities. Level of Evidence: 4.

Anatomical Study of the Chinese Nasal Keystone Region.

BACKGROUND: The keystone region is an important anatomical structure to consider in rhinoseptoplasty, because there are few published data regarding the keystone region in Chinese noses. OBJECTIVES: The authors sought to describe the anatomy of the Chinese nasal keystone region and provide useful knowledge for rhinoseptoplasty. METHODS: Sixteen cadaveric heads (11 males, 5 females) were dissected, measured, and then compared with previously published data. RESULTS: Both the nasal bone caudal margin and nasal bone-upper lateral cartilage overlapping area displayed 5 distinct shapes, and the upper lateral cartilage showed 4 distinct shapes. The nasal bone-upper lateral cartilage overlap was 6.47 mm ± 2.50 in the midline, 3.53 mm ± 2.23 on the left, and 3.81 mm ± 2.56 on the right. The length of the whole quadrangular cartilage was 25.63 mm ± 4.27; 25% ± 8% was overlapped by the nasal bone. The height of the caudal quadrangular cartilage was 18.14 mm ± 3.44, and the width of the nasal bone-upper lateral cartilage articulation was 23.56 mm ± 8.30. The upper lateral cartilage-quadrangular cartilage complex stayed in position on the maxillary crest and nasal spine, even after being dissected from the nasal bone, perpendicular plate of the ethmoid bone, and vomer. Bilateral perichondrial-periosteal mucosa detached from the nasal septum. CONCLUSIONS: We report various anatomical and structural features of the Chinese keystone region, which will be valuable for rhinoseptoplasty planning in Chinese patients.

Histological and Anthropometric Changes in the Aging Nose.

BACKGROUND: Rhinoplasty in the elderly requires different surgical approaches due to the morphological and structural changes affecting the nose over time. OBJECTIVES: In this study, the authors aimed to evaluate the age-related cellular and architectural changes of nasal cartilages and soft tissue attachments. METHODS: This prospective study included 80 patients who underwent rhinoplasty. Patients were divided into 2 groups according to age. Group I included 40 patients ranging in age from 19 to 39 years. Group II included 40 patients aged at least 40 years. Samples from nasal cartilages (upper lateral, lower lateral, and septum) and nasal attachments (interdomal, inter-cartilaginous, and septo-crural) were taken. All specimens were evaluated histologically to detect age-related changes. A modified version of the Mankin grading scale was used to score each nasal cartilage sample. All attachment samples were examined by image analysis for quantitative assessment. The results were correlated to preoperative anthropometric measurements of nasolabial angle and nasal projection. RESULTS: Histologically, in group II, the cartilage matrix showed fibrinoid degeneration with a significant decrease in the number of chondrocytes and increased perichondrial fibrosis compared with group I. Attachments in group II showed a lower number of blood vessels and decreased percentage of collagen bundles. Modified Mankin scores were significantly higher in group II, indicating weak cartilages compared with group I. There was negative correlation and significance between projection, nasolabial angle, cartilages, and attachments in study groups. The linear regression model revealed that the lower lateral cartilage is the cartilage that is most affected by the aging process. CONCLUSIONS: These findings not only enhance our current understanding of the natural changes that occur in the nose during aging but may also affect surgical decision-making when grafting or suturing are considered during rhinoplasty.Level of Evidence: 2.

Widened Dorsum: Bony and Cartilaginous Contributions.

Creation of a pleasing dorsal nasal profile in the anterior and lateral views requires proper analysis and planning to determine the required series of steps to accomplish the desired outcome. The widened nasal dorsum is a common esthetic complaint of the patient seeking rhinoplasty. Often patients seek an unrealistic result that, if accomplished, would leave them with a restricted nasal vault and nasal airway compromise. Nasal function must be balanced with the patient and surgeon's desire to narrow the nasal dorsum. Various techniques are used to control the width of the upper third, or bony vault, and middle third, or cartilaginous vault.

Alar Base Reduction and Alar-Columellar Relationship.

Nasal base modification can improve nostril shape and orientation, reduce alar flaring, improve nasal base width, correct nasal hooding, improve symmetry, and create overall facial harmony. For the correction of alar rim deformities, careful examination, consultation, and analysis and consideration of the condition of the skin are essential. Understanding the ala and surrounding tissue, supporting the lower lateral cartilage, and selecting the proper technique produce functionally and aesthetically good results.

Avaliação da modificação da técnica de reconstrução das cartilagens alares de Max Pereira no protocolo de reconstrução nasal total do Hospital de Clínicas de Porto Alegre / Evaluation of Max Pereira alar reconstruction technique modification in the total nasal reconstruction protocol of the Hospital of Clinics of Porto Alegre

Introdução: A reconstrução nasal é a mais antiga das cirurgias plásticas. A anatomia nasal é complexa e necessita de uma associação de técnicas para a restauração da função e estética nasal adequada. Pereira et al. descreveram uma técnica que possibilita a reconstrução nasal total da cartilagem alar, com o uso de um enxerto da cartilagem auricular, com mínima deformidade auricular secundária à retirada do enxerto. O objetivo deste trabalho é apresentar uma modificação da técnica acima descrita, que possibilita reconstruir mais uma região anatômica do nariz, sem aumentar a morbidade, realizada por Collares et al., e a sua inserção no protocolo de reconstrução nasal total do Hospital de Clínicas de Porto Alegre. Métodos: Foi realizado um estudo retrospectivo. Avaliou-se a inserção da modificação da técnica em 10 pacientes que realizaram reconstrução nasal total. Resultados: Após a análise dos 10 casos, utilizando a modificação da técnica inserida no protocolo de reconstrução nasal total do Hospital de Clínicas de Porto Alegre, encontramos uma melhoria da forma do nariz, a válvula nasal interna com preservação da função e sem sequelas secundárias à retirada do enxerto auricular. Conclusão: Nesta série de casos, a modificação da técnica de Max Pereira resultou em tratamento estético funcional adequado quando implementada no protocolo de reconstrução nasal total do Hospital de Clínicas de Porto Alegre, sem aumentar a morbidade na área doadora.

Introduction: Nasal reconstruction is the oldest plastic surgery technique. The nasal anatomy is complex and requires an association of techniques for the restoration of function and adequate nasal esthetics. Pereira et al. described a technique that allows total nasal reconstruction of the alar cartilage through the use of an auricular cartilage graft, with minimal deformity secondary to the donor site. The objective of the present study is to present a modification, by Collares et al., of the technique described above, which allows the reconstruction of another anatomical region of the nose without increasing morbidity, and its insertion into the total nasal reconstruction protocol of Hospital de Clínicas of Porto Alegre. Methods: A retrospective study was conducted. We evaluated technique modification in 10 patients who underwent total nasal reconstructions. Results: After examining the 10 patients who were treated with the modified total nasal reconstruction protocol at the Hospital de Clínicas of Porto Alegre, we observed an improvement in the nose shape and internal nasal valve with preservation of function, without sequelae secondary to auricular graft removal. Conclusion: In this case series, the modification of the Max Pereira technique resulted in adequate aestheticfunctional treatment when implemented in the total nasal reconstruction protocol of the Hospital de Clínicas of Porto Alegre, without increasing the morbidity in the donor area.