A Modified Technique in Rhinoplasty: A Septal Extension Graft Complex Using Septal Cartilage, Ethmoid Bone, and Auricular Cartilage.

BACKGROUND: Due to the small and weak septal cartilage of Asians, it is a challenge to obtain ideal tip projection and nose lengthening in this population by performing septal extension grafts with only septal cartilage. OBJECTIVES: The aim of this study was to introduce a septal extension graft complex incorporating nasal septal cartilage, the perpendicular plate of the ethmoid bone, and bilateral auricular cartilage, and to examine its effectiveness in terms of morphological and mechanical support. METHODS: Septal cartilage was harvested under an endoscope according to standard techniques. Two pieces of the perpendicular plate of the ethmoid bone, placed on either side of the "L" strut, served as 2 spreader grafts. A double layer of auricular cartilage was fixed as columellar strut grafts. Three-dimensional facial scanning was used to examine the change of 3 parameters. Nasal tip resistance was evaluated by a digital Newton meter. RESULTS: In total, 25 patients were followed up postoperatively for a mean of 25.9 months. The analysis showed significant differences in both contour parameters and nasal resistance: nasal length (mean [standard deviation], 41.4 [4.0] vs 46.2 [3.4] mm, P < 0.05) and nasal tip projection (21.3 [3.2] vs 24.4 [2.7] mm, P < 0.05) appeared to increase postoperatively, whereas nasolabial angle (117.6° [5.9°] vs 109.5° [5.3°], P < 0.05) showed a significant decrease after surgery. The resistance of the nasal tip also increased significantly (P < 0.05) at displacements of 1, 2, and 3 mm. All patients were satisfied with the aesthetic results, and no serious complications occurred. CONCLUSIONS: This kind of modified septal extension graft technique can effectively adjust nasal morphology for short-nose East Asians.

The ethmoid bone is the ideal graft to strengthen nasal septum L-strut among different grafts: An evaluation based on finite element analysis.

BACKGROUND: In the rhinoplasty of Asian short nose deformity, the surgeon cuts a portion of septal cartilage and retains the nasal septum L-strut, but a deviated nasal septum is formed after the surgery under forces of soft tissue contracture. Although various autologous grafts are used to reinforce the L-strut, there is a lack of objective "mechanical theory" to support the clinical findings in other studies at the present time. METHODS: A simplified and geometrical finite element model of L-strut reinforced with clinically common materials, including auricular cartilage, nasal septal cartilage, and perpendicular plate of ethmoid, was established. Simulating the mechanical environment of nasal tip in reality, when the force was loaded, the von Mises stress and directional deformation of the L-strut were observed under different widths. Kruskal-Wallis test was used to examine the significance of intergroup differences of L-strut, and P < 0.05 indicated statistical significance. RESULTS: All autologous grafts decreased the maximum directional deformation of L-strut, and the variance of nasal tip displacement was reduced; the perpendicular plate of ethmoid showed a distinct effect. The increasing width of the L-strut reduced the maximum displacement of the nasal tip, but the influence of using grafts as a reinforcement to the L-strut was much greater than the residual width (p = 0.003). CONCLUSION: The graft reinforcement significantly increased the stability of the L-strut, which enhanced the resistance to deformation in the long-term action of tension, and the effect of the perpendicular plate of ethmoid to reinforce was significantly better than that of auricular and nasal septal cartilage.

New Technique in Nasal Tip Plasty: Sandwich Technique Using Cartilage and Septal Bone Complex.

OBJECTIVES: It is extremely difficult to obtain ideal tip projection and nose lengthening by septal extension graft using only septal cartilage in Asians, because their nasal septal and alar cartilages are small and weak. Therefore, we introduce a new septal extension graft using a cartilage-bone complex with the vomer and the perpendicular plate of the ethmoid bone as well as cartilage to obtain optimal outcomes. METHODS: Participants included 30 patients who underwent surgery by external approach. The septal cartilage, vomer, and perpendicular plate of the ethmoid bone harvested by septoplasty were used. There were 2 layers of cartilage on each side and bone in between to create a strong cartilage-bone complex for projection and lengthening. The bony portion was placed in the tip side, and the double-layered cartilage portion was placed in the inferior portion of the caudal septum of the L-strut to create powerful fixation. RESULTS: There were statistically significant improvements in nasal length (4.71 ± 0.65 vs 5.15 ± 0.53 cm, P value <.0001), tip projection (2.66 ± 0.40 vs 3.18 ± 0.42, P value <.0001), and nasolabial angle (94.0° ± 9.3° vs 107.2° ± 9.6°, P value <.0001) postoperatively. All patients were subjectively satisfied, and 2 different surgeons had excellent or good opinions in 28 (94%) patients. CONCLUSIONS: The sandwich technique using cartilage and bone complex results in satisfactory outcomes with stronger tip support, especially in Asians with a weak nasal tip who desire ideal tip projection and dramatic change.

Short Nose Correction: Septal Cartilage Combined With Ethmoid Bone Graft.

BACKGROUND: Multiple methods are employed to correct short nose deformities, with septal extension graft representing the first choice for Asians. However, the volume of the septal cartilage in many Asian patients is not sufficient to be used alone for such operation. The present work developed a new method combining the septal cartilage with ethmoid bone graft to overcome this issue in Asian patients with short noses. METHODS: Thirty-five women with short noses underwent septal extension graft from February 2015 to March 2017. The endoscopic technique was utilized to harvest the ethmoid bone to enhance the L-strut structure. An L-strut, comprising 0.8 cm segments of the caudal and dorsal cartilaginous septa, is left altered in order to harvest more cartilage for septal extension. The harvested the septal cartilage, approximately 1.0 mm thick and 16 to 20 mm long, underwent grafting on one side of the caudal septum. This was followed by alar cartilage fixation at the septal cartilage graft end. Finally, nose length, nasal tip projection and nasolabial angle were assessed before and after the surgery. RESULTS: Septal cartilage combined with ethmoid bone graft yielded an adequate nose lengthening and reduced nostril show, also in individuals showing extremely little septal cartilage. CONCLUSIONS: This new method is effective for short nose deformity correction in Asian patients. Combining the septal cartilage with ethmoid bone graft yields ideal outcome without overt complications, achieving commendable patient satisfaction.

The Bony Cartilaginous Unit.

To achieve an acceptable result in septorhinoplasty, sufficient septal cartilage is needed. There are many cases in which septal cartilage is insufficient, especially in revision surgery or in some races such as Asian. To obtain an ideal outcome, a bony cartilaginous unit (septal cartilage/ethmoid bone composite graft) is proposed as a versatile graft for different purpose such as caudal extension graft.

Septal Cartilage/Ethmoid Bone Composite Graft: A New and Improved Method for the Correction Underdeveloped Nasal Septum in Patients with Short Noses.

BACKGROUND: Septal extension grafts are an effective means of extending nasal length in patients with a short nose. However, such grafts can be challenging in patients who only have small quantities of weak septal cartilage, such as some East Asian patients. We developed a rhinoplasty technique using ethmoid bone to create a cartilage-bone complex to overcome this issue, allowing adequate nasal lengthening. METHODS: Sixty-four women with short noses and inadequate septal cartilage determined by preoperative computed tomography underwent septal extension grafting with a cartilage-bone complex between January 2009 and December 2014. Septal cartilage and ethmoid bone were harvested during open rhinoplasty and secured to the septal cartilage. RESULTS: Most patients were in their twenties or thirties. All patients underwent septal extension grafting using a cartilage-bone complex and dorsal augmentation with silicone implants. Short nasal length, decreased nasolabial angle and increased nostril show, were rectified. There was no recurrence during a mean follow-up period of 12.3 months, although one patient (1.5%) requested revision surgery. CONCLUSION: Septal extension grafting with a cartilage-bone complex can be used to correct a short nose, especially in Asians who have relatively small amounts of septal cartilage. The ethmoid bone augments the inadequate septum and provides structural support. LEVEL OF EVIDENCE V: 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 .

A simple, single stage technique to harvest optimal ethmoid bone grafts for caudal septal deflections.

BACKGROUND: Curvature of the caudal septum is a challenging area to surgically address because it is a tip supporting structure. Several methods to straighten the caudal septal deviation have been described to date. One commonly described technique is the placement of a bony septal batten graft. However, the harvest and subsequent ex vivo shaping of the bone graft can be difficult and lead to fracture of the graft superstructure. Here we discuss a novel single stage endoscopic approach to harvest a preformed batten graft and apply it to correct a caudal septal curvature deformity. METHODS: Description of a novel endoscopic technique for the single stage harvest of a bone graft for the correction of a caudal septal deflection utilizing an open Jansen-Middleton septum forceps. RESULTS: We have successfully utilized this technique in 10 patients with a caudal septal curvature deformity with no complications. All patients had symptomatic improvement of nasal obstruction symptoms. CONCLUSION: The open Jansen-Middleton septum forceps allow for a reproducible, single stage, harvest of a bone graft from the perpendicular plate or vomer when addressing a caudal septal deformity using an endoscopic septoplasty approach.

Extended osteocartilaginous spreader graft for reconstruction of deviated nose.

OBJECTIVE: Correction of a deviated nose is a challenging problem for which different approaches may be considered. This study was designed to introduce a new technique for correction of a deviated nose with a high success rate. STUDY DESIGN: The study was a prospective follow-up of 59 patients with deviated nose who had undergone corrective surgery. SETTING: An extended osteocartilaginous spreader graft was harvested from the quadrangular septum and the perpendicular plate of the ethmoid. After a medial osteotomy that was performed on the concave side, the nasal bone was lateralized and an extended osteocartilaginous spreader graft was inserted between the nasal bone and the septum to prevent further retraction of the concave side due to fibrotic scar tissue. On the contralateral side, a low lateral osteotomy was done as routine. SUBJECTS AND METHODS: The operation was done on the 59 cases with deviated nose. The subjects were followed up during a period of 8 months to 4 years. According to physical examination, postoperative photography, and patients' satisfaction, the final results were categorized as excellent, fair, or poor. RESULTS: Forty-eight patients (81.3%) were categorized as having excellent results. Eight patients (13.6%) showed fair improvement, while the results of surgery in only 3 patients (5.1%) were classified as poor. CONCLUSION: An extended osteocartilaginous spreader graft, with medial osteotomy and lateralization of the nasal bone on the concave side, is a new technique with a high success rate for correction of deviated nose.

[Transnasal endoscopic reconstruction of the nasal-skull base defect to manage the cerebrospinal fluid leaks with intranasal autologous grafts].

OBJECTIVE: To explore the methods and feasibility of the transnasal endoscopic reconstruction of the nasal-skull base defect to manage the cerebrospinal fluid leaks using intranasal autologous grafts. METHOD: Ninety six nasal-skull base defect patients with cerebrospinal fluid leaks were managed under endoscope with intranasal autologous materials. The repair materials and methods for the management of the cerebrospinal fluid leaks were tailored based on the different location and size of nasal-skull base defect. Eighteen cases with nasal-skull base defects less than 0.5 cm in diameter were repaired by an overlay technique using free mucoperiosteal graft from the middle turbinate. Thirty five patients with defects in the ethmoid roof and ethmoid plate ranging in size from 0.5 to 1.0 cm in diameter were repaired by an overlay technique using a pedicled middle turbinate flaps. Twelve cases with defects in the sellar clivus ranging in size from 0.5 to 1.0 cm in diameter were repaired by an overlay technique using a pedicled septal mucoperiosteal grafts. Nineteen cases with a diameter of 1.0 to 1.5 cm defects were repaired using free septal cartilage and mucoperiosteal grafts. Seven cases with defects in the ethmoid roof and ethmoid plate ranging from 1.5 to 2.5 cm in diameter were repaired using a pedicled middle turbinate and ethmoid plate flaps. Five sellar clival defect cases ranging from 1.5 to 2.5 cm in diameter were repaired using ethmoid plate and pedicled septal mucoperiosteal flaps. RESULT: Six months to 6 years' follow up indicated that two patient developed postoperative cerebrospinal fluid leaks one year and two years after operation, respectively. One was successfully managed by conservative treatment. The other was successfully repaired by second surgery. Three patients developed transient postoperative cerebrospinal fluid leak that was spontaneous recovered without special treatment. No other new postoperative cerebrospinal fluid leaks occurred. CONCLUSION: We concluded that transnasal endoscopic reconstruction of the nasal-skull base defect is a highly effective method for managing the cerebrospinal fluid leak with the advantage of easily obtaining the intranasal autologous materials. The autologous materials should be varied based on different size and location of the skull base defects.

Uso del colgajo frontonasoorbitario para disminuir la frecuencia de complicaciones en pacientes sometidos a resección craneofacial / Use of median fronto-naso-orbital flap in order to decrease the incidence of complications in patients undergoing craneofacial resection

Antecedente: La resección de neoplasias malignas que invaden la base de cráneo anterior se realiza mediante resección craneofacial (RCF), con resultados aceptables tanto en tasas de complicaciones, como de resultados oncológicos. Sin embargo, todavía existen series cuya morbilidad se eleva hasta un 40% y en que las defunciones llegan al 5%. Se ha realizado un estudio retrospectivo para evaluar los resultados, en términos de morbilidad, mortalidad, estética y función resultantes de un colgajo óseo frontonasoorbitario (FNO). Métodos: El colgajo FNO fue usado en 28 pacientes consecutivos, que se presentaron al servicio de Cabeza y Cuello de 1992 a 1999, en el Instituto Nacional de Cancerología de la Ciudad de México y se combinó con una rinotomía superior para la resección en bloque del complejo etmoidal en los últimos 12 casos. El 89% de estos pacientes presentaban neoplasias malignas. Resultados: En esta serie hubo una defunción (3%) y la morbilidad global fue de 35%. Funcional y estéticamente, los resultados fueron de buenos a excelentes. Un 76% presentó sobrevida libre de enfermedad a los 2 años, y 41% la mantuvo por 5 años. Conclusión: La RCF constituye un método seguro para el tratamiento de las neoplasias que afectan el piso anterior de la base del cráneo; la movilización de un colgajo FNO hace disminuir las cifras de complicaciones y promete una óptima exposición para las resecciones en bloque de los tumores que invaden el complejo etmoidomaxilar, sobre todo cuando se combinan con una rinotomía superior. El resultado obtenido tuvo un impacto positivo en la calidad de vida (AU)

BACKGROUND: Resection of malignant neoplasms invading the anterior cranial base is performed with craniofacial resection (CFR) with acceptable results in complication rates and oncologic outcomes. However, still there are series with major morbidity in up to 40% of patients, and mortality of 5%. A retrospective study was performed to evaluate the results in terms of morbidity, mortality, function and aesthetics using a median fronto orbital flap (MFOF). METHODS: The MFOF was used in 28 consecutive patients who presented to the Head and Neck Service from 1992 to 1999, in the Instituto Nacional de Cancerología, Mexico City, and was combined with a superior rhinotomy for en bloc resection of the ethmoid complex in the last 12 cases. 89% of patients had malignant neoplasms. RESULTS: 1 death occurred in this series (3%) and the global morbidity was 35%. Aesthetics and function were good to excellent. Percentages of tumor-free survival for malignant lesions was 76% and 41% at 2 and 5 years follow up, respectively. CONCLUSION: CFR is a safe approach for treatment of neoplasms of the anterior skull base. MFOF mobilization decreases complication rates and gives superb exposure for en bloc resection of tumors invading the ethmoidomaxillary complex specially when combined with a superior rhinotomy. A positive impact on quality of life was obtained (AU)

[Use of median fronto-naso-orbital flap to decrease the incidence of complications in patients undergoing craniofacial resection]. / Uso del colgajo frontonasoorbitario para disminuir la frecuencia de complicaciones en pacientes sometidos a resección craneofacial.

BACKGROUND: Resection of malignant neoplasms invading the anterior cranial base is performed with craniofacial resection (CFR) with acceptable results in complication rates and oncologic outcomes. However, still there are series with major morbidity in up to 40% of patients, and mortality of 5%. A retrospective study was performed to evaluate the results in terms of morbidity, mortality, function and aesthetics using a median fronto orbital flap (MFOF). METHODS: The MFOF was used in 28 consecutive patients who presented to the Head and Neck Service from 1992 to 1999, in the Instituto Nacional de Cancerología, Mexico City, and was combined with a superior rhinotomy for en bloc resection of the ethmoid complex in the last 12 cases. 89% of patients had malignant neoplasms. RESULTS: 1 death occurred in this series (3%) and the global morbidity was 35%. Aesthetics and function were good to excellent. Percentages of tumor-free survival for malignant lesions was 76% and 41% at 2 and 5 years follow up, respectively. CONCLUSION: CFR is a safe approach for treatment of neoplasms of the anterior skull base. MFOF mobilization decreases complication rates and gives superb exposure for en bloc resection of tumors invading the ethmoidomaxillary complex specially when combined with a superior rhinotomy. A positive impact on quality of life was obtained.

Bone and temporal fascia graft for the closure of septal perforation.

OBJECTIVES: To assess the reliability of temporal fascia and bone graft for the closure of septal perforation. STUDY DESIGN: Prospective longitudinal non-randomized. METHODS: The repair of septal perforation was performed using endonasal dissection; suture of the borders of the perforation on at least one side, and interposition of a graft of temporal fascia with bone, either a perpendicular plate of ethmoid (six) if available or mastoid cortex (three) if not. RESULTS: All patients had closure without re-perforation. Eight out of nine patients had complete closure of the perforation (88.8 per cent). These patients had perforations of less than 3 cm in diameter. The ninth patient had a perforation of more than 3 cm diameter (3.5 x 2.5 cm), and obtained a closure of about 80 per cent of the original perforation. The remaining perforation was in the posterior part of the nose. The patient was relieved of his symptoms (crusting and bleeding). This incomplete closure was most probably due to migration of the graft immediately after surgery. There was no morbidity of the donor site or the ear in the mastoid cortex graft group of patients. This is to our knowledge the first report of the use of the mastoid cortex as a graft in septal perforation. CONCLUSIONS: We consider that the graft of temporal fascia with bone is very reliable, and the use of bone ensures closure while avoiding the complications of a lax septum in large perforations. The technique is suitable for perforations up to 2.5 cm diameter. Perforations larger than 3 cm in diameter are more difficult to close, but closure of the anterior part of the perforation will relieve the patient from the most annoying symptoms.

The osteo-mucoperiosteal flap in repair of cerebrospinal fluid rhinorrhea.

Repair of fistulas producing cerebrospinal fluid rhinorrhea, as with any reconstructive operations, should take into account the basic principles of reconstructive surgery for best results: 1. tissue needing replacement should be replaced by like tissue; and 2. a flap is always superior to a graft. In the case of this disease, the tissue sealing the fistula should be a flap containing not only mucosa or mucoperiosteum, but also pedicled bone. Two kinds of regional flaps are described which successfully closed the fistula in each of three patients. Follow-up is long term.