Lower Lateral Cartilage Cephalic Malposition: An Over-Diagnosed Entity.

BACKGROUND: Lower lateral cartilage malposition is represented by anterior convexity of the lower lateral cartilage (LLC) dome with posterior pinch, as defined by Sheen and Constantian. This anatomic variation consists of cephalic, or upward and inward, rotation of lateral crura, particularly in bulbous tip patients. In most cases, "bulbous pinch" LLC is positioned toward the medial canthus, not laterally, so it is referred to as cephalic displacement. Accordingly, it is recommended to caudally displace cartilage in the majority of rhinoplasty cases in which variation is seen. OBJECTIVES: The purpose of this paper is to measure the exact angle of lateral crura with fixed reference points on the face. METHODS: We drew and marked LLC contours and vertical/horizontal lines in 40 consecutive rhinoplasty cases. We then divided them into two groups: (1) bulbous pinch and (2) flat LLCs. The right- and left-sided LLC angles to midline and horizontal lines were measured and compared to assess whether there was any significant difference between the two subgroups. RESULTS: There was no significant difference between the angles of LLC rotation in the bulbous and flat LLCs groups, measured both vertically and horizontally. CONCLUSION: Based on our findings, although cephalic malposition of LLCs may be present in some patients but in the majority of cases the etiology of nasal lateral wall pinching is not cephalic displacement of lateral crura but most probably is due, rather, to severe convexity of the posterior and lateral crura. According to our findings, cephalic malposition is an uncommon anatomic variation of LLCs that has been reported at high frequency (60-70% of their rhinoplasty cases). This finding may help to correct this deformity into a normal anatomic configuration. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Angiogenic Potential of Human Bone Marrow-Derived Mesenchymal Stem Cells in Chondrocyte Brick-Enriched Constructs Promoted Stable Regeneration of Craniofacial Cartilage.

Craniofacial deformities caused by congenital defects or trauma remain challenges for clinicians, whereas current surgical interventions present limited therapeutic outcomes. Injection of bone marrow-derived mesenchymal stem cells (BMSCs) into the defect is highly desirable because such a procedure is microinvasive and grafts are more flexible to fill the lesions. However, preventing hypertrophic transition and morphological contraction remain significant challenges. We have developed an "all host derived" cell transplantation system composed of chondrocyte brick (CB)-enriched platelet-rich plasma (P) gel and BMSCs (B). Without exogenous biomaterials or growth factors, such grafts regenerate cartilage efficiently and present great clinical promise. In immunodeficient mice, we compared performance of BMSCs and BMSCs lacking angiogenic potential in CB-B-P constructs and followed the cartilage maturation process by histology, immunostaining, micro-computed tomography, and protein analysis. We determined that angiogenesis occurred quickly inside rudimentary cartilage derived from CB-B-P constructs after implantation, which improved tissue survival, tissue growth, and production of chondrogenic signals from chondrocytes. In contrast, silencing angiogenic potential of BMSCs led to poor chondrogenesis accompanied by necrosis. Chondrocyte bricks merged rapidly with angiogenesis, which constituted an enclosed chondrogenic niche and effectively inhibited runt-related transcription factor-2-dependent hypertrophic transition of BMSCs as well as endochondral ossification; progressive chondrogenic differentiation of BMSCs resulted in vascularization regression, thus favoring persistent chondrogenesis and effectively augmenting nasal cartilage. In conclusion, these findings provided a novel, efficient approach to regenerating cartilage tissues in vivo. Chondrocyte bricks mixed with P provide transient vascularization and a persistently chondrogenic microenvironment for BMSCs; this provides a mini-invasive approach for craniofacial cartilage reconstruction. Stem Cells Translational Medicine 2017;6:601-612.

Alar Contour Grafts in Rhinoplasty: A Safe and Reproducible Way to Refine Alar Contour Aesthetics.

BACKGROUND: Alar rim deformities such as retraction, notching, collapse, and asymmetry are common problems in rhinoplasty patients. Although alar rim deformities may be improved through rhinoplasty, this area is prone to late changes because of scarring of the soft triangles and a paucity of native structural support. The purpose of this study was to analyze the effect of alar contour grafts on primary rhinoplasty. METHODS: Fifty consecutive primary rhinoplasty patients with preoperative and postoperative photographs who received alar contour grafts were evaluated for alar aesthetics; 50 consecutive primary rhinoplasty patients without such grafts served as controls. Differences among alar retraction, notching, collapse, and asymmetry from anterior, lateral, and basal views were evaluated. Follow-up ranged from 1 to 4 years and was graded on a four-point scale. RESULTS: The average difference between the two groups' aggregate preoperative scores was 0.21 (p = 0.24). The average preoperative and postoperative scores in the nongraft group were significant for worsening retraction, notching, and collapse but insignificant for asymmetry. The preoperative and postoperative scores for the graft group were insignificant for retraction but improved significantly for notching, collapse, and asymmetry. Postoperatively, the aggregate average of the scores in the nongroup was 0.32 points worse (p < 0.01), whereas the graft group had a 0.33-point improvement (p < 0.01). CONCLUSIONS: Alar contour grafts have a clear and important impact on cosmetic results of primary rhinoplasty. Use of alar contour grafts has been shown to improve aesthetics, whereas there is a worsening of the measured parameters postoperatively without use of these grafts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Finite Element Model Analysis of Cephalic Trim on Nasal Tip Stability.

IMPORTANCE: Alar rim retraction is the most common unintended consequence of tissue remodeling that results from overresection of the cephalic lateral crural cartilage; however, the complex tissue remodeling process that produces this shape change is not well understood. OBJECTIVES: To simulate how resection of cephalic trim alters the stress distribution within the human nose in response to tip depression (palpation) and to simulate the internal forces generated after cephalic trim that may lead to alar rim retraction cephalically and upward rotation of the nasal tip. DESIGN, SETTING, AND PARTICIPANTS: A multicomponent finite element model was derived from maxillofacial computed tomography with 1-mm axial resolution. The 3-dimensional editing function in the medical imaging software was used to trim the cephalic portion of the lower lateral cartilage to emulate that performed in typical rhinoplasty. Three models were created: a control, a conservative trim, and an aggressive trim. Each simulated model was imported to a software program that performs mechanical simulations, and material properties were assigned. First, nasal tip depression (palpation) was simulated, and the resulting stress distribution was calculated for each model. Second, long-term tissue migration was simulated on conservative and aggressive trim models by placing normal and shear force vectors along the caudal and cephalic borders of the tissue defect. RESULTS: The von Mises stress distribution created by a 5-mm tip depression revealed consistent findings among all 3 simulations, with regions of high stress being concentrated to the medial portion of the intermediate crus and the caudal septum. Nasal tip reaction force marginally decreased as more lower lateral cartilage tissue was resected. Conservative and aggressive cephalic trim models produced some degree of alar rim retraction and tip rotation, which increased with the magnitude of the force applied to the region of the tissue defect. CONCLUSIONS AND RELEVANCE: Cephalic trim was performed on a computerized composite model of the human nose to simulate conservative and aggressive trims. Internal forces were applied to each model to emulate the tissue migration that results from decades of wound healing. Our simulations reveal that the degree of tip rotation and alar rim retraction is dependent on the amount of cartilage that was resected owing to cephalic trim. Tip reaction force is marginally reduced with increasing tissue volume resection. LEVEL OF EVIDENCE: NA.

Importance of nasal septal cartilage perichondrium for septum strength mechanics: a cadaveric study.

OBJECTIVE: This study aimed to investigate the biomechanical qualities of the perichondrium and cartilage, and to determine the strength of the septal cartilage against bending forces. STUDY DESIGN: This paper describes an experimental cadaver study. MATERIALS AND METHODS: The nasal septal cartilages of 14 fresh cadavers (8 hours postmortem) were excised from the cadavers and cut into two strips: one with the perichondrium (group A) and one without perichondrium (group B). A bending test was then performed on the strips. RESULTS: The deflection of group A strips was larger than the deflection of group B strips. Flexural strength was also larger in group A strips compared to group B strips. The average modulus of elasticity was 122% higher in group A compared to group B. All conducted tests revealed statistically significant differences between groups. CONCLUSION: This study objectively shows that the perichondrium provides the cartilage with a 25% bending strength.

Alar retraction: etiology, treatment, and prevention.

IMPORTANCE: The effect of different rhinoplasty maneuvers on alar retraction remains to be elucidated. OBJECTIVE: To determine the etiology and treatment of alar retraction based on a series of specific rhinoplasty maneuvers. DESIGN: Retrospective review of a single surgeon's rhinoplasty digital photo database, examining preoperative alar retraction from January 1, 2002, to December 31, 2005, in 520 patients. Patients with more than 1 mm of alar retraction on preoperative photographs were identified. Postoperative photographs were examined to determine the effect of specific rhinoplasty maneuvers on the position of the alar margin; these maneuvers included cephalic trim, cephalic positioning of the lower lateral cartilage, composite grafts, alar rim grafts, alar batten grafts, and overlay of the lower lateral cartilage. SETTING: Tertiary care academic health center. PARTICIPANTS: Forty-five patients with alar retraction met inclusion criteria, resulting in 63 nasal halves with alar retraction. MAIN OUTCOMES AND MEASURES: Intraoperative findings, postoperative results. RESULTS: Forty-seven percent of the patients (n = 21) had prior surgery; 47% also had cephalically positioned lower lateral cartilages. Among patients with less than 4 mm of cartilage width at the outset, 46% of those who received supportive grafts achieved target correction vs only 7% for patients who did not undergo supportive cartilage grafting. In patients who underwent more than 4 mm of cephalic trim, those who received supportive grafts achieved 46% of target correction vs 11% among those who did not. Ninety-five percent of composite grafts, 69% of alar strut grafts, 47% of alar rim grafts, 43% of vertical lobule division, and 12% of alar batten grafts achieved their target correction values. CONCLUSIONS AND RELEVANCE: Alar retraction is a highly complex problem. It can be seen de novo and is associated with cephalically positioned lower lateral cartilages. Structurally supportive grafting-including composite grafts, alar strut grafts, alar rim grafts, vertical lobule division, and alar batten grafts-can improve alar retraction. LEVEL OF EVIDENCE: 4.

Anterior septal deviation and contralateral alar collapse.

INTRODUCTION: Septal deviation is often found in conjunction with other pathological conditions that adversely affect nasal patency. Anterior septal deviation, together with contralateral alar collapse, is a relatively rare type of anatomical and functional incompetence. In our experience, it can often be resolved with septoplasty, without the necessity of surgery involving the external valve. The aim of this paper was to verify this hypothesis prospectively. PATIENTS AND METHODS: Twelve patients with anterior septal deviation and simultaneous alar collapse on the opposite side were prospectively enrolled in the study. Subjective assessment of nasal patency was made on post-operative day 1, and again 6 months after surgery, using a subjective evaluation of nasal breathing. The width of the nostril (alar-columellar distance) on the side with the alar collapse was measured during inspiration pre-operatively, 1 day after surgery and again 6 months after surgery. RESULTS: Immediately after surgery, all patients reported improved or excellent nasal breathing on the side of the original septal deviation. On the collapsed side, one patient reported no change in condition. With the exception of one patient, all measurements showed some degree of improvement in the extension of the alar-columellar distance. The average benefit 6 months after surgery was an improvement of 4.54 mm. CONCLUSION: In our group of patients (anterior septal deviation and simultaneous contralateral alar collapse and no obvious structural changes of the alar cartilage) we found septoplasty to be entirely suitable and we recommend it as the treatment of choice in such cases.

The caudal septum angle of deflection: an objective analysis for caudal septum deviation.

OBJECTIVES: The purposes of the study were to describe an objective technique for the evaluation of caudal septum deviation (CSD) and to evaluate the effectiveness of an open septorhinoplasty technique for treatment of CSD. STUDY DESIGN: A retrospective review of septorhinoplasty cases involving CSD was performed. For all patients, preoperative basal view photographs were analyzed. All patients underwent an external septorhinoplasty approach for treatment of their CSD. After a minimum of 4 months, postoperative basal view photographs were analyzed. RESULTS: Seventeen patients had significant CSD and airway obstruction. The mean change in their caudal septum angle of deflection was 22° (P < .05). All patients had subjective improvement in their nasal airway obstruction. There were no complications. CONCLUSION: We describe a method to objectively analyze CSDs in septorhinoplasty candidates. An external approach using nasal base reconstruction techniques results in an improvement of CSD and subsequent nasal airway patency.

Nasal strips for evaluating and classifying valvular nasal obstruction.

BACKGROUND: A normal-appearing upper lateral cartilage (ULC) or lower lateral cartilage (LLC) may be functionally abnormal. The Cottle sign estimates obstruction but not its exact location. A test is needed that evaluates the ULC and LLC separately. METHODS: The study included 30 patients with airway obstruction symptoms and signs referable only to the nasal valves. They received a Cottle test and a Breathe-Rite nasal strip to the middle third of the nose and again to the lower third (the rims). The patients were asked whether the strip made their inspiration better, worse, or no different and classified as BR 0 (no airway obstruction due to ULC/LLC dysfunction), BR I (improvement with the strip on the ULC), BR II (improvement with the strip on the LLC), or BR III (improvement with strips on both the ULC and the LLC, independently). All the patients underwent surgery involving spreader grafts, lateral crural struts, suture techniques, and the like. Correlations were sought between the BR classification, Cottle sign, and physical integrity of the ULC/LLC. RESULTS: A total of 12 patients required internal valve correction, whereas 8 required external valve correction, and 10 required correction of both. The Cottle test was nonspecific because most patients in all the groups exhibited a positive Cottle. However, the BR classification was specific, correlating with functional outcomes for 27 of the 30 patients. The McNemar test showed a significant correlation (Χ(2) = 9.09091; P = 0.00257) between physical finding and BR score. CONCLUSIONS: Inspiratory nasal function (related to ULC/LLC cartilages) is easily classified using nasal strips. The BR test is more specific and powerful than the Cottle test.

Preventing alar retraction by preservation of the lateral crus.

BACKGROUND: Resecting the cephalic component of the lateral crus in an attempt to reduce tip bulbosity has the potential to aggravate and/or cause alar retraction. It is a more serious problem for those patients who exhibit borderline alar retraction. METHOD: Fourteen primary rhinoplasty patients with borderline alar/columellar relationships for alar retraction formed the study. They did not warrant frank treatment of alar retraction but did exhibit tip bulbosity. An "island" of cephalic lateral crus was developed by an intercartilaginous incision and another 6 mm cephalic to the caudal border of the lateral crus. One or more mattress sutures were placed in the main body of the lateral crus to stiffen and straighten it. The "island" of cephalic crus was then slipped under the main body of the lateral crus. RESULTS: At 11 months to 2(1/2) years, 13 of the 14 patients demonstrated no significant change in their preoperative alar/columellar relationships. Bulbosity was corrected in all patients. One patient, however, required a revision using an alar contour rim graft. The mean preoperative alar-nostril axis measurement was 1.48 mm (range, 1.3 to 1.9 mm) in contrast to a mean postoperative measurement of 1.71 mm (range, 1.5 to 2.2 mm). A one-tailed paired t test indicated no statistically significant difference between preoperative and postoperative values. CONCLUSIONS: The cephalic part of the lateral crus can act as a lateral crural strut to maintain the ala in a more caudal position. The technique is useful for borderline alar retraction and when lengthening the short nose for which there is a need to preserve side wall length.

[Rhinosurgery in children: developmental and surgical aspects of the growing nose]. / Rhinochirurgie bei Kindern: Entwicklungsphysiologische und chirurgische Aspekte der wachsenden Nase.

The anatomy of the nasal skeleton in newborns and adults are not alike. The complete cartilaginous framework of the neonatal nose becomes partly and gradually ossified during the years of growth and is more vulnerable to trauma in that period. Injury in the early youth may have large consequences for development of a nasal deformity which will increase during growth and reach its peak during and after the adolescent growth spurt. To understand more of the underlying problems of nasal malformations and their treatment (septoplasty) these items became the focus of multiple animal studies in the last 40 years. The effects of surgery on the nasal septum varied considerably, seemingly depending on which experimental animal was used. In review, however, it appeared that the very different techniques of surgery might be even more influential in this respect. Study of one of the larger series of experiments in young rabbits comprised skeletal measurements with statistical analysis and microscopic observations of the tissues. The behaviour of hyaline cartilage of the human nose appeared to be comparable to that of mammals. Cartilage, although resilient, can be easily fractured whereas its tendency to integrated healing is very low, even when the perichondrium has been saved. Also surgical procedures - like in septoplasty - may result in growth disturbances of the nasal skeleton like deviation or nasal spine. Loss of cartilage, as might occur after a septum abscess, is never completely restored despite some cartilage regeneration. In this article the many experimental studies are reviewed and compared. Still there remains a lack of real consensus in the literature concerning the developmental effects of rhinosurgry in children. Based on their observations in animals and a few clinical studies, mostly with small numbers of patients but with a long follow-up, the authors have compiled a list of guidelines to be considered before starting to perform surgery on the growing midface in children.

The effect of alar cinch sutures and V-Y closure on soft tissue dynamics after Le Fort I intrusion osteotomies.

UNLABELLED: Adverse effects on the soft tissues after Le Fort I osteotomies include: broadening of the alar base, loss of vermilion show of the upper lip and down sloping of the commissures. In theory, an alar cinch suture combined with a muco-musculo-periosteal V-Y closure (ACVY) should improve not only the nasal width, but would also improve the dynamics of some of the mimic muscles. To test the validity of this hypothesis, a prospective study was set up including 22 patients, using standardized full facial frontal photographs, taken immediately preoperatively and 18 months postoperatively. Sets containing three pictures were made: soft tissue in repose, maximum closed mouth smile and maximum smile. The landmarks, alare, crista philtri and cheilion were analysed. The preliminary results show that ACVY-closure does significantly improve the horizontal movement of cheilion with both maximum closed mouth smile and maximum smile, as well as the vertical movement of crista philtri with maximum closed mouth smile. CONCLUSION: The Le Fort I osteotomy with ACVY improves the orofacial dynamics.

Long-term results after using dynamic presurgical nasoalveolar remodeling technique in patients with unilateral and bilateral cleft lips and palates.

OBJECTIVE: To evaluate the effects and durability of results after using dynamic presurgical nasoalveolar remodeling in patients with unilateral and bilateral cleft lips and palates. METHOD: Dynamic presurgical nasoalveolar remodeling technique does not rely on the relatively static force exerted by the orthopedic plate held in place by means of tape or adhesives. The principle behind this procedure is the use of the force generated during suction and swallowing to produce the remodeling effects on the nasal structures. The nasal component acts not only on the nasal structures but also in the lip function by stimulating labial muscle contraction. Direct anthropometry performed before primary reconstruction of the lip and nose and 1 year later posterior to surgery suggests that results are permanent. CONCLUSIONS: When the dynamic presurgical nasoalveolar remodeling protocol is instituted early, it can avoid memory cartilage fixation. Changes incorporated to the nasal extension allowed us to obtain better results, elevating the nasal tip, remodeling the depressed cleft side alar cartilages in unilateral cases, and repositioning and correcting the positional alteration of the nasal cartilages building a new columella in bilateral cases. In addition, comfort and tolerance of patients has been improved, and adjustments needed during follow-up have been simplified, significantly reducing the consultation time and increasing the interval between appointments. The obtained outcome facilitates primary surgical cleft lip and nose reconstruction and improves surgical results.