Structural Approach to Secondary Repair of the Unilateral Cleft Lip Nasal Deformity.

SUMMARY: Management of the unilateral cleft lip nasal deformity is complex because of the underlying significant asymmetry of the lower lateral cartilages and soft tissues of the nasal base. Suturing and grafting techniques may leave the patient with residual asymmetries of the nasal tip and nostrils. Some of this residual asymmetry may be attributable in part to the anchoring effect of the vestibular skin attachments to the lower lateral cartilages. This article discusses the use of lateral crural release, repositioning, and support with lateral crural strut grafts to manage the nasal tip. The technique involves freeing the vestibular skin from the undersurface of the lateral crura and domes and placement of lateral crural strut grafts with or without amputation of the ipsilateral dome and lateral crura to allow precise resuturing to the caudal septal extension graft. This technique is coupled with the use of a caudal septal extension graft to stabilize the nasal base and provide a strong foundation for the repair. Treatment of the nasal base may require skeletal augmentation to aid in creating symmetry of the alar insertions. Costal cartilage is needed in most cases to provide adequate structural support. Nuances in technique are discussed to help maximize outcomes.

Lateral Crural Repositioning: Implications on Nasal Function.

There are many concepts for surgical management of the nasal tip with varying outcomes on esthetics and nasal function. Nasal tip surgery can influence nasal function based on how the techniques can alter lateral wall integrity. A retrospective chart review of rhinoplasty patients undergoing lateral crural strut grafting (LCSG) with and without repositioning from 2009 to 2017 of the primary author (D.M.T.) was performed. Preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE) scores were analyzed. In our study, 832 subjects were evaluated. The mean preoperative NOSE score of all subjects was 35.48. The longest follow-up mean was 652.07 days with a mean NOSE score of 7.07 (p < 0.0001). In the LCSG group, the mean preoperative NOSE score was 22.97. The longest follow-up mean was 583.29 days with a mean NOSE score of 7.22 (p < 0.0001). In the LCSG with repositioning group, the mean preoperative NOSE score was 43.42. The longest follow-up mean was 692.36 days with a mean NOSE score of 7.60 (p < 0.0001). LCSGs with or without repositioning improves nasal function showing significant improvement in NOSE scores. The use of these techniques require adhering to several technical points to maximize outcomes and to avoid deformity.

Commentary on: "Septal Advancement Flap" by Ferriera: Caudal Septal Extension Graft, Columellar Strut, or the New Septal Advancement Flap.

The septal advancement flap is introduced as a new technique to support the nasal base in preservation rhinoplasty. The SAF is a septal flap composed of the caudal septum in continuity with the high strip incision used in dorsal preservation. The technique is supported with a strut of cartilage between the medial crura. The SAF has been evaluated using mathematical models and a finite element mesh to verify the stability of the graft. The SAF is compared with the caudal septal extension graft and columellar strut and discussed in the context of all three options for stabilizing the base of the nose in rhinoplasty. The pros and cons of each as well as details about refinements of the caudal septal extension graft are discussed.

Advanced Preservation Rhinoplasty in the Era of Osteoplasty and Chondroplasty: How Have We Moved Beyond the Cottle Technique?

BACKGROUND: Over the last 10 years, many new papers on innovative strategies from different surgeons worldwide have elevated the philosophy of preservation rhinoplasty (PR) to a different level: advanced preservation rhinoplasty. OBJECTIVES: The goal of this article was to illustrate how 4 experienced surgeons approach important anatomical and functional issues related to PR. METHODS: M.G.F., A.M.K., B.S., and D.M.T. were asked about how they approach classical problems and relative contraindications for dorsal PR with different modern advanced preservation rhinoplasty techniques. RESULTS: The answers of each surgeon make clear a new reality in dorsal PR that did not exist in the recent past. These advances in dorsal PR techniques are due to many surgeons' contributions, leading this practice to a different level: advanced preservation rhinoplasty. CONCLUSIONS: Dorsal preservation is making a dramatic resurgence and is fueled by the many very talented surgeons who are demonstrating outstanding outcomes with preservation techniques. The authors believe that this trend will continue, and a mutual collaboration between structuralists and preservationists going forward will continue to advance rhinoplasty as a specialty.

Auricular Composite Graft Survival in Rhinoplasty.

Auricular composite grafts can be used in rhinoplasty to correct defects of the internal nasal valve, ala, vestibule, sill, and external nose. The objective of this study was to measure the auricular composite graft (ACG) survival rate and patient-reported outcome with Nasal Obstruction Symptom Evaluation (NOSE) score among patients undergoing rhinoplasty. A retrospective chart review was performed of all patients who underwent rhinoplasty with ACGs from 2002 to 2019 by the senior author. Median patient age was 42 years (range 14-79) with 80.3% being female. In total, 234 rhinoplasty procedures were performed utilizing 367 auricular composite grafts. Secondary rhinoplasty (n = 160, 68.4%) was the most common. And 93.7% of ACGs had full take. There were 23 partial or total graft failures, producing graft failure rate of 6.3%. Mean preoperative NOSE score was 24.08, and mean postoperative NOSE score was 21.84, with a p-value of 0.63. Auricular composite grafts can be used to repair a wide range of defects of the internal nasal valve, nasal sill-ala junction, nasal vestibule, and external nose.

Subdorsal Cantilever Graft: Indications and Technique.

The subdorsal cantilever graft (SDCG) is a costal cartilage graft that is positioned below the nasal dorsum to control the position of the nasal bones and middle nasal vault. SDCG type A is used to raise the middle nasal vault and caudal nasal bones to correct the saddle nose deformity. SDCG type B can be used to raise the entire dorsum of the nose (radix, bony vault, and middle vault) in the ethnic augmentation rhinoplasty patient. This article will discuss the indications and technique of the SDCG in dorsal preservation rhinoplasty.

My First Twenty Rhinoplasties Using Dorsal Preservation Techniques.

Dorsal preservation involves eliminating the dorsal hump by performing reduction while preserving the patient's natural dorsal anatomy. This can involve surface manipulation or foundational techniques or a combination of both. When surgeons begin performing dorsal preservation, there are important factors to consider to avoid complications. In an effort to inform surgeons on how to avoid unfavorable outcomes, I will discuss my first 20 cases where I performed dorsal preservation. I review less than ideal outcomes and how these issues can be prevented.

Correction of the Saddle Nose Deformity Using the "Push Up" Technique.

The saddle nose deformity typically occurs after the loss of underlying septal support with loss of projection of the middle nasal vault. This creates a saddling effect as the upper lateral cartilages contract and forms a dip in the profile. The saddle nose deformity can occur from many different etiologies, including septal hematoma, fracture of the septum after trauma, disruption of the dorsal L-strut support after septoplasty, and metabolic disorders resulting in the loss of septal support. In most cases, the nasal bones remain in their native position creating a discrepancy in dorsal height and deformity. Correction of the saddle nose deformity can be performed using one of the two primary approaches. The most basic option is to simply fill the defect with a cartilage onlay graft (solid graft, diced cartilage and fascia, and so on) to create a normal dorsal line. This approach can be effective in many cases. Over time, the onlay graft may descend and create deformity or become visible. The other approach involves opening the middle nasal vault, placing spreader grafts, and reconstituting the dorsal L-strut, performing septal reconstruction or extracorporeal septoplasty. In this paper, we present our technique of repairing the saddle nose deformity using a "push up" method that preserves the middle vault anatomy and reconstitutes the proper projection of the middle-third of the nose.

Subdorsal Cantilever Graft for Elevating the Dorsum in Ethnic Rhinoplasty.

Augmentation of the nasal dorsum is frequently required in the ethnic rhinoplasty patient to create a narrowing effect and to balance the upper two thirds of the nose with the desired increase in tip projection. The subdorsal cantilever graft (SDCG) provides a method to elevate the nasal dorsum to complement the increase in nasal tip projection. SDCG type A is situated below the bony dorsum and acts to raise the dorsum with limited elevation of the radix. The SDCG type B extends through a radix osteotomy site and raises the radix down to the supratip after complete release of the bony dorsum and middle nasal vault. Placement of the SDCG below the dorsum has many advantages, including preserving the features of the natural dorsum (dorsal aesthetic lines), controlled narrowing, and camouflage of the subdorsal graft. This is a complex procedure that requires a good understanding of dorsal preservation techniques. Use of the SDCG to raise the nasal dorsum in ethnic patients combines structure rhinoplasty with the principles of dorsal preservation for augmentation of the profile in patients with a low dorsum.

Radiographic Assessment of the Nasal Septum and Trends in Donor Cartilage Availability.

Objective: To compare the harvestable donor septal cartilage among patients. Background: Trends in donor septal cartilage anatomy are not well quantified in the literature. Methods: Harvestable septal cartilage area and length (preserving a 1-cm L-strut) were measured on fine-cut maxillofacial computed tomography (CT) for 200 patients in four self-described racial/ethnic groups: African American, Asian American, European American, and Latin American. Height, sex, and age were recorded. Demographic variables were modeled by multivariate logistic regression to determine characteristics predictive of harvestable septal cartilage. Results: Older age, shorter height, African American or Asian American self-described race, and female sex were independently associated with smaller harvestable area and shorter length (all p < 0.05). On multivariate regression, Asian American [odds ratio (OR) 5.23, p = 0.005] and African American (OR 3.75, p = 0.015) patients were more likely than Latin American or European Americans patients have a smaller harvestable area. Age (OR 1.02, p = 0.043) and height (OR 0.94, p = 0.029) were also correlated with smaller cartilage area and length, respectively. Conclusions: CT scan and demographic characteristics predicted donor septal cartilage availability.

Correction of the Saddle Nose Deformity Using the "Push Up" Technique.

The saddle nose deformity typically occurs after the loss of underlying septal support with loss of projection of the middle nasal vault. This creates a saddling effect as the upper lateral cartilages contract and forms a dip in the profile. The saddle nose deformity can occur from many different etiologies, including septal hematoma, fracture of the septum after trauma, disruption of the dorsal L-strut support after septoplasty, and metabolic disorders resulting in the loss of septal support. In most cases, the nasal bones remain in their native position creating a discrepancy in dorsal height and deformity. Correction of the saddle nose deformity can be performed using one of the two primary approaches. The most basic option is to simply fill the defect with a cartilage onlay graft (solid graft, diced cartilage and fascia, and so on) to create a normal dorsal line. This approach can be effective in many cases. Over time, the onlay graft may descend and create deformity or become visible. The other approach involves opening the middle nasal vault, placing spreader grafts, and reconstituting the dorsal L-strut, performing septal reconstruction or extracorporeal septoplasty. In this paper, we present our technique of repairing the saddle nose deformity using a "push up" method that preserves the middle vault anatomy and reconstitutes the proper projection of the middle-third of the nose.

Structural Preservation Rhinoplasty: A Hybrid Approach.

SUMMARY: Structural preservation rhinoplasty merges two popular philosophies of rhinoplasty-structure rhinoplasty and preservation rhinoplasty-in an effort to maximize patient outcomes, aesthetics, and function. This allows the surgeon to both preserve the favorable attributes of the nose, and also to structure the nasal tip and dorsum with grafts to maximize contour and support. The concept of dorsal preservation is to preserve favorable dorsal aesthetic lines without the creation of an "open roof." However, the addition of some structure concepts can expand the utility of dorsal preservation in primary rhinoplasty patients. The authors discuss these structure concepts and their applicability to dorsal preservation.