Nuances of the nasal tip: rhinoplasty of the thin-skinned nose.

Rhinoplasty in the thin-skinned patient presents a unique set of challenges to achieve desired results. Preoperative recognition of thin skin is imperative to direct the operative plan and to achieve excellent results. Once identified, meticulous care must be implemented in sculpting the underlying cartilaginous framework. The skin may also benefit from techniques to thicken the skin through the use of cartilage and fascial grafts. This article will discuss recognition of the thin-skinned nose, avoiding pitfalls, techniques to optimize structural support, camouflage grafting techniques, and options available to thicken the nasal skin.

Subcutaneous implants coated with tissue-engineered cartilage.

OBJECTIVE: To investigate the ability to coat two alloplastic implants, porous high-density polyethylene (PHDPE) and expanded polytetrafluoroethylene (e-PTFE), with tissue-engineered cartilage (TEC) from human septal chondrocytes in a mouse model. STUDY DESIGN: Prospective study. METHODS: PHDPE and e-PTFE disks were coated with alginate impregnated with human septal chondrocytes and implanted into athymic nude mice. A control group consisting of PHDPE and e-PTFE disks coated with alginate only were implanted. Gross, histological, and biochemical characteristics of the TEC constructs were examined at 10 and 20 weeks following implantation. RESULTS: One animal in the experimental group and one animal in the control group died. Implants coated with TEC were successfully generated in 18 (94.7%) mice in the experimental group (n = 19) and in zero (0%) of the control group (n = 17). The final weight of each harvested specimen decreased in the control group and increased in the experimental group, when compared with preimplant weight. Mean decrease in weight in the control group was greater at 20 weeks than at 10 weeks (P = .017). Mean increase in weight in the experimental group was greater at 20 weeks than at 10 weeks (P = .009). The diameter of the control group decreased, while the diameter of the experimental group was maintained. The reduction in diameter was less in the experimental group than in the control group at 10 (P = .018) and 20 weeks (P = .01). Gross and histological examination confirmed the formation of neocartilage, with characteristics similar to native cartilage, in the experimental group at 10 and 20 weeks. Glycosaminoglycan content in the experimental group at 20 weeks was approximately 80% of that measured in implanted human septal cartilage. Cartilaginous and fibrovascular ingrowth into implant pores was more extensive in the PHDPE than the e-PTFE experimental group. CONCLUSIONS: Implants coated with TEC from human septal cartilage can be reliably produced in the athymic nude mouse model. Maintenance of shape, as measured by the conservation of construct diameter, is possible. Fibrovascular ingrowth and cartilage formation into the pores of the alloplastic implants was observed. This integration of a construct composed of a synthetic implant coated with TEC may improve the performance of alloplastic implants through better long-term fixation and increased resistance to infection.

Functional considerations in revision rhinoplasty.

The development of nasal obstruction after rhinoplasty is associated with significant patient dissatisfaction. Correction of nasal obstruction requires a thorough evaluation to determine the ANATOMIC EPICENTER of obstruction. The offending structure can usually be traced to abnormalities in the internal nasal valve, intervalve area, or the external nasal valve and may be static or dynamic. Surgical correction of the internal nasal valve using spreader grafts, flaring sutures, and butterfly grafts has been shown to increase the cross-sectional area of this nasal valve, improving nasal airflow and patient satisfaction. External valve dysfunction from cicatricial stenosis may be addressed with local flaps; however, larger stenoses may require composite grafts. Alar base malposition can be addressed by repositioning of the alar base with local island flaps. Intervalve dysfunction involves the important area between the external and internal valves, under the supra-alar crease, and is the most common site of obstruction. Its correction often involves alar batten grafts and reconstruction of the lateral crura. Inferior turbinate hypertrophy and concha bullosa may be addressed as adjunctive therapy to increase nasal airflow. This article on nasal obstruction after rhinoplasty emphasizes the precise anatomic diagnosis and describes successful methods used to correct the dysfunction.

Functional rhinoplasty: treatment of the dysfunctional nasal sidewall.

Treatment of nasal obstruction caused by nasal valve dysfunction requires a thorough evaluation of the mechanics of normal nasal anatomy and function. Surgical correction of nasal valve dysfunction is based on determining the epicenter of dysfunction, whether it is a static obstruction of the internal nasal valve or a dynamic collapse of either the external nasal valve or the intervalve area. Spreader grafts, flaring sutures, and butterfly grafts are used to widen and support the narrow internal nasal valve. Alar batten grafts will add support to the collapsing nasal sidewall seen in external nasal valve and intervalve dysfunction. Correction of dynamic collapse from paradoxical concavity of the lateral crura may be obtained from the lateral crural flip-flop graft or by reconstructing the lateral crura using cartilage grafts. A strut graft may correct dynamic obstruction caused by a malformed, easily collapsible lateral crura. This article discusses the evaluation, treatment, and correction of the dysfunctional nasal sidewall and emphasizes the avoidance of iatrogenic damage to the sidewall while performing cosmetic rhinoplasty.