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Nasal bone length remains a commonly referenced attribute when referring to the aesthetic nose. Short nasal bone length is suggested to predispose to a greater risk of middle vault collapse after rhinoplasty. We report on normative measurements of nasal bones and associated structures in Thai cadavers. Using twelve adult cadavers, common external nasal landmarks were identified and measured to approximate the dimensions of the nasal bones and upper lateral cartilages. These clinically relevant surface landmarks were correlated to direct measurements of dissected nasal bones and the upper lateral cartilage in these same cadavers. Additionally, external landmarks of ten volunteers were examined. The average measured length of the nasal bone was 19.00 mm; the average measured length of the upper lateral cartilage was 13.15 mm. Measurements obtained via external landmarks were 17.60 mm and 13.05 mm respectively. The relationship of the nasal bone internal length to the external measurement (A) was a ratio of 1.10:1, whereas the internal length of the upper lateral cartilage to the corresponding external measurement (B) was 1.04:1. On average the nasal bones contributed to 59% of the middle vault nasal sidewall. The average length of the Thai adult nasal bone is 19.00 mm while that of the upper lateral cartilage is 13.15 mm. The relationships of the accepted external landmarks to the underlying anatomic structures were established using a t test. This normative data will generate useful parameters when evaluating the Asian rhinoplasty patient. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s12070-020-02044-z) contains supplementary material, which is available to authorized users.

Background The smooth and straight nasal dorsum is a goal after nasal hump reduction as dorsal irregularities are unexpectable and inevitable complications. The aim of this study is to evaluate modified perichondrial-periosteal flaps functionally and aesthetically to camouflage nasal dorsal irregularities. A total of 115 patients with nasal humps were enrolled in the study. The perichondrium over the upper lateral cartilages is divided in the midline and dissected forming two laterally based flaps while the periosteum over the nasal bones is dissected superiorly. After completion of all rhinoplasty steps, the flaps were repositioned and sutured as a separate layer. Follow-up for 2 years with an assessment of irregularities of the nasal dorsum, collapse of the upper lateral cartilage, and nasal breathing. Results Aesthetically, no nasal dorsal irregularities were noticed. Also, no patients complained of nasal obstruction. Conclusion The modified perichondrial-periosteal flap is a successful technique, functionally and aesthetically. It avoids the appearance of dorsal irregularities.

To determine: (1) rates and risk factors for progression of lateral and medial full-thickness cartilage defect size in older adults without severe knee osteoarthritis (OA), and (2) whether risk factors for defect progression differ for knees with Kellgren–Lawrence OA grade 3 (moderate) OA versus grades 0–2 (none to mild) OA. Three-hundred and eighty adults enrolled in the Osteoarthritis Initiative were included (43% male, mean age 63.0 SD 9.2 years). Ethical approval was obtained at all study sites prior to enrollment. All participants had full-thickness tibial or weight-bearing femoral condylar cartilage defects on baseline knee MRIs. Baseline OA grade was KL grade 3 in 71.3% and grades 0–2 in 21.7% of participants. Repeat MRIs were obtained at a minimum 2-year follow-up. Independent risk of progression in defect size due to demographic factors, knee alignment, OA grade, knee injury and surgery history, and baseline knee symptoms was determined by multivariate Cox proportional hazards and linear regression modeling. The average increase in defect size over 2 years for lateral defects was 0.18 cm2 (SD 0.60) and for medial defects was 0.49 cm2 (SD 1.09). Independent predictors of medical defect size progression were bipolar defects (beta 0.47 SE 0.08; p

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. The purpose of this paper is to measure the exact angle of lateral crura with fixed reference points on the face. 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. There was no significant difference between the angles of LLC rotation in the bulbous and flat LLCs groups, measured both vertically and horizontally. 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. 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 .

Cephalic resection of the lateral crura of the alar cartilages, lateral osteotomies, and removal of the nasal hump during rhinoplasty may cause collapse of the internal nasal valve angle. This study was performed to compare preventive effects of two techniques (spreader grafts and flaring sutures) on rhinoplasty by rhinomanometry. Two hundred and forty-eight patients participated in this semi-experimental study. The patients were assigned into two groups. 28 of them were not available for follow-up. All patients had a straight nose in the midline and no severe septal deviations. 87 of 220 patients underwent the spreader grafts technique and the flaring sutures technique was performed in 133 patients. The nasal airway resistance was calculated by active anterior rhinomanometry on admission to hospital and again between 3 and 6 months following surgery. The mean of follow-up was 20.9 ± 2.9 weeks. After rhinoplasty, nasal airway resistance decreased in 46 patients (52.9 percent) of spreader grafts group and in 84 patients (63.2 percent) of flaring sutures group. The median nasal airway resistance difference (before-after surgery) of spreader grafts and flaring sutures groups was 0.027 Pa/ml/s (range -110 to 130) and 0.017 Pa/ml/s (range -0.690 to 0.790), respectively. The difference of nasal airway resistance between before and after rhinoplasty in two groups was insignificance (Mann-Whitney U test, P = 0.5). The spreader grafts and flaring sutures move the dorsal border of the upper lateral cartilage in a lateral direction and had similar preventive effect on nasal airway resistance after rhinoplasty.

Although many methods have been proposed to restore the internal nasal valve (INV) such as suture techniques, various grafts, upper lateral cartilage folding techniques, and combined techniques, the most popular and effective one remains spreader grafts. The aim of the present study is to propose a new graft design for INV reconstruction and to test the reliability and feasibility of the technique. Thirty-two primary septorhinoplasty patients divided in three groups underwent surgery with railway, spreader, and no graft techniques. The functional results were evaluated with the Nasal Obstruction Evaluation Scale (NOSE) scores subjectively. Significant improvements were observed comparing preoperative and postoperative NOSE scores in railway and spreader grafts groups. However, there was no significant difference in NOSE scores between those groups of patients. Railway graft is an effective method that can be recommended if septal cartilage is limited for reconstruction of INV. Level of Evidence: Level IV, therapeutic study.

Currently, clinicians better understand the functional and aesthetic consequences of a cephalic malpositioned lateral crus of the lower lateral cartilage, which was identified 30 years ago. Functionally, cephalic malpositioning causes alar support deficiency, which results in external valve insufficiency. Cosmetically, it causes alae nasi retraction, alar bracket deformity, boxiness, and underprojection of the nasal tip. The stair-step technique, defined by Boccieri and Raimondi, is an effective repositioning technique for the repair of this deformity. The strengthened stair-step technique, a combination of the lateral crural-rim graft and the stair-step technique, is described in this article. In this study, designed as a prospective case series, the strengthened stair-step technique was performed for 62 patients (43 women and 19 men; mean age, 27.3 years) between November 2009 and December 2012. Because 12 patients did not attend follow-up visits regularly, their outcomes could not be evaluated. These patients were excluded from the study. Pre- and postoperative photos of all the patients were taken. Aesthetic evaluations showed that six patients were not satisfied with their results, four patients had complaints about the nasal tip (1 had asymmetry and 3 had alar stiffness and/or thickness), and two patients had nasal dorsum complaints. Functional evaluation showed that four patients had slight dissatisfaction with their breathing. They reported continuing collapse in the valve area with inspiration. The remaining patients were satisfied with their results. The strengthened stair-step technique is a safe and effective technique for correcting not only lateral crus cephalic malpositioning but also alar rim retraction and external valve collapse. 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 .

Isolated congenital nasal anomalies that cause remarkable aesthetic deformities are extremely rare, and only a few cases have been reported in the literature. In this study, we present the case of a patient with nonsyndromic congenital isolated absence of the nasal lower lateral cartilage and the subsequent esthetic surgical correction. A satisfactory result was achieved. Level of Evidence: Level V, therapeutic study.

Excessive concavities of the lower lateral crura can lead to heavy aesthetic disfigurement of the nasal tip and to insufficiencies of the external nasal valve. This study reviewed experience with the lower lateral crural reverse plasty technique that uses the existing cartilage to create the desired lower lateral cartilage contour and provides sufficient alar rim support. A retrospective review was conducted with a follow-up period ranging from 9 to 33 months. The technique was applied in primary (n = 13) and secondary (n = 3) open rhinoplasties to correct severe concavities of the lower lateral cartilages. Two case examples and intraoperative photographs are presented to illustrate the technique and its results. The lower lateral crural reverse plasty proved its applicability for the functional and aesthetical correction of severe lower lateral crura concavities. By dissecting the distorted lateral crus, turning it around, and suturing it back in place, surgeons can “reconstruct” a new lateral crus with existing cartilage. No additional cartilage is needed, and no harvesting at a different location needs to be performed. After rhinoplasty, no alar rim instabilities were observed. In three cases, even preexisting instabilities were corrected. Aesthetically enduring results were observed, and no overcorrection or alar retraction was seen. With the lower lateral crural reverse plasty, severe concavities of the lower lateral crura can be corrected. This technique is a useful and reproducible procedure, performed without additional tissue to achieve functionally and aesthetically satisfying and enduring results.

In most references to the nasal anatomy, the shape of the lower lateral cartilage (LLC) is described as a two-dimensional structure. However, the authors have found different forms of LLC in at least 40% of their open rhinoplasty cases during the past 20 years. This cartilage was found to have a three-dimensional hemispheric appearance and to be connected to the upper lateral cartilage (ULC) at the scroll area by an inward limb of this hemisphere. This inward limb may have an important role in producing asymmetry and flare of the nostril.The LLC of 286 patients was evaluated during open rhinoplasty over a 2-year period, with a focus mainly on the shape of this structure, especially at the LLC-ULC junction (scroll area).A dome-shaped appearance of the LLC was noted in 40.9% of cases, and 11.5% of cases had bilateral LLC variation. This different anatomic form was seen mostly in patients with a strong bulbous nasal tip, although it was observed less frequently also in patients with narrow nasal tips.At least one-third of the LLCs analyzed had a medial wall in addition to the lateral wall, which significantly increased the flare and recoil force of this structure. This makes this cartilage more redundant to reshaping procedures (straightening). Thus, special attention must sometimes be paid to this common anatomic variation to produce symmetric nostrils and to obtain a more aesthetically acceptable alar tip.

A novel technique for maintaining internal nasal valve anatomic and physiologic integrity at the time of hump reduction is proposed. The procedure involves mobilizing the anterior edge of the upper lateral cartilage after submucosal dissection. Reduction of the anterior border of the septal cartilage and reconstruction of the middle vault of the nose is accomplished by placing the upper lateral cartilage medial border on the reduced edge of the septum using a vest-over technique. The technique was successfully used for 32 nonconsecutive patients over a 4-year period.

The primary emphasis of the operation to achieve maximum nasal lengthening is based on: (l) a release of soft tissue including the mucoperichondrium; (2) release of the soft tissue between the upper lateral cartilage and the lower lateral cartilage; and (3) attachment of a batten graft to the septum to project the tip cartilages caudally. Case examples of the results of the open approach are given. In those cases in which the closed technique must be used, a modified technique is utilized. This involves a hemitransfixion incision and elevation of the mucoperichondrium bilaterally, followed by a batten graft.

In an experimental study on rabbit knees, regeneration of the medial meniscus occurred following 9 out of 10 meniscectomies, compared with only 1 out of 10 lateral menisci. Degenerative changes in the articular cartilage were seen in 8 of 9 knees where the lateral cartilage failed to regenerate, but in only 2 of 9 with a regenerated medial cartilage. The rate of regeneration is lower after lateral meniscectomy and this may partially explain the occurrence of more severe degenerative changes after this operation.