Improving Nasal Tip Projection and Definition Using Interdomal Sutures and Open Approach Without Transcolumellar Incision

The object of this study was to maximally take advantage of the combination of two surgical techniques to manage the nasal tip. For this, an approach similar to the open tip approach without a transcolumellar incision was performed and the management of the alar cartilages with multiple combined sutures was carried out. This study represents more than two years of work where 57 primary and secondary rhinoplasty patients were operated on. In all of them, the nasal tip was managed by means of utilizing different types of sutures in the alar cartilages, according to the characteristics and needs of each patient. At the same time, an extensive lipectomy was performed on the nasal tip, if indicated. All of the nasal tip surgeries were performed with an open approach without transcolumellar incision. This approach has been previously described, is highly simple, and it eliminates the principal disadvantage of a transcolumellar scar that arises from the open approach technique. Although the scar is hardly noticeable in Caucasian patients, in non-Caucasians it could constitute an important undesirable effect. This approach permits us to manage the cartilages using sutures in many diverse types and variations in a more complete form, similar to which one could achieve using the classical open approach technique. The results are highly satisfactory and result in a definition and rotation of the nasal tip which would be difficult using the closed technique. Therefore, this study represents another alternative surgical technique in the surgical management of the nasal tip.     

Open rhinoplasty without transcolumellar incision

Traditional open rhinoplasty leaves a scar on the columella. No one can say that this scar is invisible. It is less noticeable in Caucasian patients but it is a problem in non-Caucasian patients like in our country. To avoid such a scar and still obtain a wide exposure of the nasal framework, the bilateral paramarginal incisions close to the columella were extended down to the nasal floors. The lower lateral cartilages forming the nasal tip could then be delivered out through one of the nostrils. An exposure similar to the traditional open rhinoplasty was then achieved. The technique has been used in 23 patients with satisfactory results. In conclusion, the open rhinoplasty without transcolumellar incision can replace the traditional transcolumellar open rhinoplasty technique in selected patients.     

自体鼻中隔软骨与膨体聚四氟乙烯假体联合隆鼻术

目的：探讨鼻中隔软骨与膨体聚四氟乙烯（expanded polytetrafluoroethylene,ePTFE）联合隆鼻治疗鼻尖过低、鼻孔显露的手术方法,以减少单纯假体隆鼻术的并发症。方法：采用鼻正中蝶形切口加双侧鼻翼缘切口取鼻中隔软骨,行鼻中隔软骨联合ePTFE加强型补片隆鼻术并治疗鼻尖低平。结果：术后随访1～6年,评价360例就医者手术效果,优157例,占43.6%;良196例,占54.4%;一般7例,占2%;无效果差的病例。结论：应用鼻中隔软骨联合ePTFE在隆鼻术中治疗鼻尖过低、鼻孔显露,可以明显减少单纯假体隆鼻术的并发症,效果理想。     

Closed Rhinoplasty with Marginal Incision: Our Experience and Results

Supporters of traditional rhinoplasty and promoters of open rhinoplasty have debated their approaches for many years. From among different possible techniques, a surgeon must always choose the approach that provides the best aesthetic result. The surgeon’s experience and artistic sense are essential for the closed technique, whereby most of the corrections are performed without exposing the nasal frame. The open technique allows a greater operating range with a direct view of the nasal structure, resulting in improved precision in modeling the cartilages. However, the absence of intact skin cover exposes the surgeon to a less precise overall aesthetic evaluation. This report highlights the marginal technique, described in 1990 by Guerrerosantos, which uses a two-sided circular incision permitting complete dissection of the alar cartilages and the overhead skin cover of the columella. This approach, together with the extramucous technique, permits complete exposure of the skin and nasal septum without a columella incision. Therefore, the marginal technique is suitable for primary rhinoplasty cases in which complex modeling of the nasal tip and an excellent aesthetic result are required.     

Dissection of the medial crura as a standard procedure in rhinoplasty: Case studies

In the systematic approach to rhinoplasty, the author routinely uses an intercartilaginous columellar incision for dissection and reconstruction of the nasal tip, especially to facilitate separation of the tip cartilages from other tissues in the lower third of the nose. This technique has been used by the author for more than ten years and its advantages are demonstrated.     

Dissection of the medial crura as a standard procedure in rhinoplasty: case studies

In the systematic approach to rhinoplasty, the author routinely uses an intercartilaginous columellar incision for dissection and reconstruction of the nasal tip, especially to facilitate separation of the tip cartilages from other tissues in the lower third of the nose. This technique has been used by the author for more than ten years and its advantages are demonstrated.     

耳软骨在二次隆鼻术及鼻尖成形术中的应用

目的：探索二次隆鼻术及鼻尖成形术的方法。方法：采用鼻小柱“飞鸟”形切口加鼻翼软骨缘切口,切开分离皮肤、皮下组织,显露假体并取出,分离两侧鼻翼软骨及侧鼻软骨等,将取下的耳软骨缝合固定于新雕刻假体的顶部及短壁上,插入鼻背固定,缝合双侧穹窿部鼻翼软骨,缝合切口。结果：自2010年6月～2013年6月对46例不满意隆鼻术行二次隆鼻及鼻尖成形术,获得满意的手术效果。术后鼻尖形态自然、鼻长度延长、高度增加、歪鼻也得到矫正等。结论：用自体耳软骨及硅胶假体行二次隆鼻术及鼻尖整形术,能解决鼻尖不良形态,矫正鼻偏斜、鼻孔外露、增加鼻长度,获得鼻部整体形态自然协调的效果,是一种理想的手术方法。     

Nasal tip refinement in primary rhinoplasty: The cephalic trim cap graft

Background: Commonly used techniques for achieving nasal tip projection and refinement are adequate for most primary rhinoplasty patients, but they may result in undesirable tip bifidity and visible lower lateral cartilage angularity, especially in patients with thin skin. Objective: We report the use of “like” local tissues, cephalic trim cartilage remnants of the lower lateral cartilages, as invisible tip grafts to soften any angular cartilage edges or tip bifidity. Methods: The cartilaginous framework was exposed by using the open rhinoplasty approach. Lower lateral cartilages were separated from upper lateral cartilages, the caudal septum at the anterior septal angle, and from each other. A cephalic trim was performed as necessary, with the cartilaginous segments preserved for use as a cap graft. Interdomal sutures and transdermal sutures were used either alone or in combination to set the desired tip projection. If tip bifidity was visible through thin nasal tip skin, a cephalic trim cap graft was placed. Results: The procedure can achieve a well-unified nasal tip with no evidence of bifidity, angularity, or cartilage graft visibility. Conclusion: Use of this technique to improve nasal tip projection can avoid undesirable tip bifidity and visible lower lateral cartilage angularity in patients with thin nasal skin. (Aesthetic Surg J 2002;22:39-45.)     

Rhinoplasty. The Difficult Nasal Tip: Total Resection of the Alar Cartilages

There are many ways to reconstruct and make nasal tips more attractive. Sometimes we cannot find the best way unless we at least remove all surplus from the tip. This may occur in primary or secondary rhinoplasty. In principle, anything is possible when relocating and reconstructing. However, sometimes we face reality when we uncover the tip: broken or bulging cartilages that are difficult to put right. For this reason, in 1987 we thought of totally resectioning the alar cartilages in a case of secondary rhinoplasty with an unsightly appearance. After a year the result was seen to be correct from an aesthetic and a functional perspective and is still so today. Aesthetically, it kept its shape and did not collapse with nasal respiratory failure. We covered the end of the crus medialis with a small, temporary, one- to two-layered fascia patch. Except in exceptional cases, we now use this procedure: Total sectioning of the alar cartilages including the domes, or maintenance of them by preserving the fibroadipose tip tissue with a suture in the middle of the end of the crus medialis and by covering this with temporary fascia, which usually has two layers depending on the thickness of the skin of the tip. This procedure is indicated mainly in secondary rhinoplasty when the cartilages of the tip are completely destroyed, and in primary rhinoplasty when the tip is excessively wide and bulbous. Our philosophy is, therefore, elegance and beauty of the nasal tip with a solid and equilateral base without prejudices.     

Early surgical treatment of Cyrano-nose haemangiomas with Rethi incision.

Nasal haemangiomas may cause great social distress. Complete involution of these haemangiomas does not usually result in a return to normality. The subcutaneous tumour infiltrates the alar cartilages, resulting in a globular aspect of the nasal tip. In this location, haemangiomas are slow to regress, and contour deformities result from the fibrofatty tissue that remains after total involution and also from definitive deformation of the nasal cartilages. Surgery to remove the affected tissue and preserve the anatomy seems to be the best treatment for these tumours. We report six cases of nasal haemangiomas removed using the Rethi incision and a double rim incision. This procedure allows complete dissection of the tumour, and leaves only a small scar. The alar cartilages are returned to their anatomical position to allow normal growth. Surgery is performed at around 2 years of age; skin excision is not necessary because spontaneous skin retraction occurs. Our patients were evaluated by their parents, the surgeon and members of the dermatology staff not involved in their treatment. Pain, scar and final aspect were evaluated using statistical analysis. The parents and surgeon rated the postoperative results as very satisfactory or satisfactory. The dermatology staff also reported improvement after surgery. The scar is nearly invisible and the procedure allows excision of large nasal haemangiomas.     

The effect of releasing tip-supporting structures in short-nose correction

Correction of a short nose has been regarded as one of the most challenging and at times vexing procedures in rhinoplasty. One surgical option used to prolong nasal length is the freeing of the alar cartilages from adjacent structures by dividing the nasal tip supporting tissues. Five fibrous connections are known to be important in maintaining the nasal tip shape: fibrous tissues between the upper lateral and lower lateral cartilages; the lateral border of the lower lateral cartilages at the pyriform aperture; the interdormal ligament and anterior septal angle; the footplate of the medial crus and septal cartilage; and the dermocartilaginous ligament. This study was designed to determine which of the fibrous connections providing nasal tip support offer the most effect of lengthening when these structures are divided. We performed 10 open rhinoplasties on fresh cadavers, and we sequentially divided the previously mentioned tip-supporting structures, except the dermocartilaginous ligament. The mucoperichondrium of the upper lateral and septal cartilages was also elevated, in accordance with the usual order of being released in a short-nose correction procedure. We measured the distance between the anterior septal angle and tip-defining points by using calipers while the middle crura of the lower lateral cartilages were stretched with a skin hook. We found that the most effective length was gained by severing the lateral crus from the upper lateral cartilages, and moderate gain was noted from the release at the pyriform aperture and mucoperichondrium of the upper lateral cartilage. Release of other tip-defining structures was not statistically effective.     

自体耳软骨与硅胶假体联合隆鼻术

目的探讨应用耳软骨加强鼻尖部自体组织的厚度,并与硅胶假体联合置入隆鼻的方法。方法取适当的耳甲腔软骨雕刻成型,附在硅胶假体鼻尖部,置入鼻背筋膜下,进行隆鼻。结果本组患者39例,其中2例术后1周出现假体偏斜,1个月后自然好转;1例术后6个月假体鼻根部活动并抬高,经再次手术后满意。余患者随访6个月至2年,效果满意。结论应用耳软骨可加强鼻尖部自体组织厚度,耳软骨联合硅胶假体隆鼻术可避免假体下滑、移位和外露等并发症的出现,值得临床推广应用。     

自体耳软骨与硅胶假体联合隆鼻术

目的探讨应用耳软骨加强鼻尖部自体组织的厚度,并与硅胶假体联合置入隆鼻的方法。方法取适当的耳甲腔软骨雕刻成型,附在硅胶假体鼻尖部,置入鼻背筋膜下,进行隆鼻。结果本组患者39例,其中2例术后1周出现假体偏斜,1个月后自然好转;1例术后6个月假体鼻根部活动并抬高,经再次手术后满意。余患者随访6个月至2年,效果满意。结论应用耳软骨可加强鼻尖部自体组织厚度,耳软骨联合硅胶假体隆鼻术可避免假体下滑、移位和外露等并发症的出现,值得临床推广应用。     

自体耳软骨联合自体真皮组织在假体隆鼻修复术中的应用

目的:探讨应用自体耳软骨与自体真皮组织以增加鼻尖部与鼻背部组织高度,并联合假体材料进行隆鼻修复术。方法:取耳甲腔软骨雕刻成形,固定在假体鼻尖部;取颞部头侧真皮,覆盖在假体背部表面,将此复合假体置入原有鼻背隧道内。结果:本组患者25例,随访6个月～1年,无假体变形及皮肤坏死,患者对假体外形及透光度等方面的改善效果满意。结论:应用自体耳软骨增加鼻尖组织高度,自体真皮组织增加鼻背组织高度,在隆鼻修复术中能有效解决原有隆鼻术造成的鼻尖及鼻背组织变薄发亮、假体轮廓不自然等不良并发症。     

Open tip rhinoplasty along with the repair of cleft lip in cleft lip and palate cases.

This paper is a report on a procedure to perform open tip rhinoplasty at the time of lip repair in unilateral and bilateral cleft lip and palate deformity. A total of 69 patients who had this operation between 1994 and 1997 have been reviewed. Conventionally there is hesitation to do radical nasal correction for the cleft lip patient because of the fear of possible growth retardation. The present technique, while it achieves excellent postoperative results constantly, does not entail any more trauma to the cartilage complex than any of the conventional closed rhinoplasty techniques. Early results obtained by this method appear to be superior to those by closed rhinoplasty techniques.     

Ist die geschlossene Rhinoplastik überholt?

Closed rhinoplasty has been performed for over 50 years. Advantages over the open approach lie in the avoidance of unnecessary skin retraction and damage, as well as a better overview during surgery. In addition, transplantations are less frequently required. The present article describes the closed approach to rhinoplasty, including septum correction, hump removal, nasal bridge augmentation and nasal tip reshaping. Additionally, the use of a mastoid composite bone graft in nasal corrections is recommended and described for the first time. By using similar bone types and autologous tissue, particularly natural and well-tolerated results can be achieved.     

鼻翼及鼻尖肥大的美容整复

目的:探讨矫正鼻翼鼻尖肥大的最佳手术方法。方法:依鼻翼、鼻尖肥大的特点,采取横向缩小鼻翼法,并注重鼻翼外侧脚的移位。鼻尖整形行开放式手术入路,重塑鼻翼软骨,并把切除下的鼻翼组织块去表皮后置到鼻假体上。结果:30例鼻翼鼻尖肥大患者均取得了良好的手术效果。结论:鼻翼、鼻尖肥大要整体诊治,才能取得良好的手术效果。     

Preservation of the Nasal Valve Area With a Lateral Crural Hinged Flap: A Cadaveric Study

Background  

Overresection of the lateral crura of the lower lateral cartilages is referred to as the most common cause of nasal valve collapse after rhinoplasty. The modern approach to functional rhinoplasty recognizes the importance of the tip framework’s structural integrity and preserves tip support.