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The same surgical principle as for the unilateral cleft applies for the bilateral cleft lip, alveolus, and palate, and the results should be equivalent to those for the unilateral cleft lip. The fundamental aim of the repair of a cleft lip-nose deformity lies in the release of the abnormally attached and displaced anatomical structures, followed by meticulous realignment. The release must be sufficient to allow a tension-free closure for an optimal healing process. The closer and the more aligned these anatomical structures are, the less surgical release is necessary. This results in less scarring, and potentially more favorable growth is expected. Finally, a balanced lip and a symmetrically oriented alar base and lower lateral cartilage with normal tip projection must be achieved. In this chapter the author introduces a step-by-step approach to the reconstruction of the lip and the nose that could be used in any bilateral case.

The visibility of cartilage grafts underneath the skin is a complication of rhinoplasty particularly in patients with thin nasal skin. Preparing the graft with optimum dimensions, symmetry, and smoothness is crucial for the fine crafting of the cartilage to prevent visibility. The camouflage of the visible cartilage graft with a crushed cartilage, a resected cephalic portion of the lower lateral cartilage, fascia, connective and/or fatty tissues is another option for hiding the visibility. The nasal tip is the most common location where the graft visibility is of concern.The authors introduce the smoothing of the cartilage graft by sanding it with a scalpel. This technique safely provides perfection and precision of smoothing of the cartilage in very desired shape. It is possible to obtain 3D super clean-cut shining surface.The tangential sculpting of the cartilage graft with a scalpel carries the risk of over resection. However, the sanding with a scalpel moves forward so gentle that over resection is not possible.It is also possible to smooth non-visible structural grafts such as strut and spreader grafts to reduce surface irregularities.Additionally, the sand-dust caused by cartilage sanding is a 'cartilage pâté' which can be used for camouflage of minute irregularities of the nasal dorsum.

Background:. Asymmetry is a common occurrence in bilaterian animals, particularly human beings. Through examination of patients and their photographs during rhinoplasty, we noted wider left-sided nasal and facial features in most patients. This observation led us to hypothesize that this might be consistent to the whole body. Methods:. We conducted a study in 3 parts to test the question above. First, we analyzed operating notes of 50 rhinoplasty patients to determine the wider side of the upper, middle, and lower thirds of the nose. Second, we analyzed the width of the face and chest wall in 31 patients to discern any correlation between facial and bodily asymmetry. Third, computerized tomographic scans of the thorax and body of 48 patients were studied to measure the width of the hemithorax and hemipelvic bone. Results:. (1) Upper vault width was wider on left side (78%). Left middle vault width was wider (88%). The lower lateral cartilage, lateral crura convexity was more prominent on left side (48%), and a wider scroll area was found and trimmed in 21 (left) and 0 (right) cases. The alar base was wider on left side (56%). (2) In the body and face analysis, 64.5% had a wider left-sided face and body. (3) In the computed tomographic scan analysis, same-sided thorax and pelvis asymmetry was seen (85.35%), 33 and 7 of which were left- and right-sided, respectively. Conclusion:. We observed generalized asymmetry of the face and body with left-sided predominance.

This case series report describes use of lower lateral cartilage measurements in evaluating the nasal tip shape in Asian patients.

Asian patients undergoing cosmetic rhinoplasty often want surgeons to concentrate on the broad nasal tip. Modifying the cartilage framework is considered to be the fundamental strategy; during the modification procedures, the cephalic portion of the lower lateral cartilage is often excised and discarded. However, given the supporting function and volumetric filling properties of autologous cartilage, the cephalic cartilage should and can be salvaged by using our cruciate overlap technique.To introduce a novel technique in modification of broad nasal tip in Asian patients undergoing rhinoplasty and assess its efficacy and safety.Dissection of 5 fresh cadaver head specimens was performed and the plausibility and reliability of the new procedure were determined at Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. In addition, the cruciate overlap technique was performed in 43 Chinese patients between January 1, 2011, and December 31, 2013, and the surgical results were assessed subjectively and objectively during the follow-up period, ranging from 12 to 36 months, with the final follow-up November 30, 2014. Anthropometric measurements of patients' noses preoperatively and postoperatively were taken and the patients' complications were reviewed.Cadaveric evaluation, subjective and objective assessments of the surgical results (rated on a scale of 1 to 4, with 4 indicating much improvement from the preoperative level), nasal measurements of the patients, and evaluation of the complications.The mean size of the cartilaginous flap in the cruciate overlap technique was 12.0 mm long and 3.0 mm wide, allowing for 180° rotation and graft coverage, with the nasal cartilage framework protected from collapse. Mean (SD) scores for the subjective and objective judgment of the outcomes were 3.3 (0.4) and 3.5 (0.3), respectively. Moreover, nasal measurements demonstrated significant postoperative improvement by increasing the mean nasal tip protrusion (from 14.3 [1.5] to 16.7 [2.0] mm) and reducing the mean tip width (from 22.7 [1.7] to 18.2 [1.6] mm) and tip angle (from 101.0° [6.3°] to 87.7° [6.7°]) (all P .001). Acceptable ranges of edema, ecchymosis, and pain were observed in the early postoperative period and resolved within a short period. No aesthetic or functional adverse effects were reported during the follow-up period.The cruciate overlap technique is an efficacious and reliable alternative for modification of broad nasal tips in Asian patients undergoing rhinoplasty.4.

The cleft nasal deformity is a prevailing problem of complex challenge for plastic surgery, especially in the secondary correction. We mainly chose 40 patients with unilateral secondary cleft lip nasal deformity with alar collapse. Based on biomechanics and anatomy of nasal cartilage, we adapt a Z-plasty with cartilage mucosa using the deformed lateral crus of the upper lateral cartilage to support the collapse of lower lateral cartilage. All of our patients were satisfied with the aesthetic morphology after surgery, so we are confident that this method should be considered as an auxiliary treatment to rhinoplasty.

The upper lateral cartilages underlie the nasal bones cephalically, and articulate with the nasal septum medially. The authors studied the histologic and anatomical relationships between the lateral aspect of the upper lateral cartilages and the frontal process of the maxilla.Six cadaver noses were dissected by open rhinoplasty to expose the upper lateral cartilages bilaterally. Subperiosteal dissection was performed over the medial maxillae and nasal bones to expose the perimeter of the pyriform aperture. Twelve sides were analyzed anatomically. Three cadavers were used to create six tissue specimens for histologic analysis, by resecting the tissue of the upper lateral cartilage-maxillary bone articulation en bloc.Grossly in all specimens, the upper lateral cartilage articulated with the frontal process of the maxilla laterally, lying deep to the coronal plane of the maxillary bone. In four histologic specimens, the upper lateral cartilage was found to underlie the frontal process of the maxilla laterally, displaying an overlapping relationship. In the other two histologic specimens, the upper lateral cartilage ended medial to the maxilla. In all specimens, the ends of the upper lateral cartilage and maxilla articulated by way of a pyriform ligament.The upper lateral cartilage articulates laterally with the frontal process of the maxilla by means of the pyriform ligament, with a variable amount of overlap between the upper lateral cartilage and maxilla. Relationships among the upper lateral cartilage, maxilla, and pyriform ligament affect the configuration of the lateral internal nasal valve area, and should be considered when planning internal nasal valve reconstruction.

Introduction: Nasal tip revision remains one of the most challenging procedures for plastic surgeons. Performing 3-dimensional anatomic nasal tip reconstruction by complete replacement of alar cartilages with ear cartilage allows optimal nasal tip correction in patients with severe alar distortion. We aim to describe this reconstructive surgical technique and report our experience with this procedure. Materials and Methods: We performed a retrospective analysis of patients who underwent complete replacement of alar cartilages as part of a revision rhinoplasty. Results: From January 2010 to December 2014, 569 patients underwent revisions, 20 (3.5%) of them with complete alar replacement. Additional grafts used were as follows: 8 columellar struts, 6 onlay grafts, and 3 spreader grafts. There were no in-hospital complications. At follow-up (mean 24 months), all patients reported satisfaction with the esthetic outcome and improvement in functional symptoms. No patient underwent further augmentation or repeat revision. Conclusions: Complete replacement of alar cartilages is an efficient surgical alternative for nasal tip reconstruction during revision rhinoplasty. This technique recreates the severely injured alar cartilage structure and returns the original nasal tip appearance.

Congenital isolated alar defects are extremely rare, occurring in approximately 1 in 20,000 to 40,000 live births. The patients are presented here of 2 pediatric patients operated on for congenital isolated alar defect. The reconstruction of congenital isolated alar defects was made in a 3-layered fashion. The skin defects were covered using the Mutaf triangular closure technique in which 2 cutaneous local flaps are designed in an unequal Z-plasty manner. Conchal cartilage graft was used between the skin and mucosal closure to replace the missing part of the lower lateral cartilage in these patients. The early results were promising in Patient 1, but sufficient improvement was detected in the alar cartilage postoperative follow-up period in Patient 2. Hence, this patient required revision 1 to 2 years postoperatively. This technique provides excellent aesthetic and functional results, except for this problem in Tessier 2 cleft patients. The use of the Stair step flap technique with Mutaf triangle closure technique achieved cosmetically and functionally excellent results in the reconstruction and repair of a large, irregular, narrow cleft, in the inadequate rotation of the lateral part of the lower lateral cartilage. However, because of this problem, evaluation of the long-term follow-up of patients is necessary.

The nasal tip refinement is the most difficult stages of rhinoplasty surgery; whereas, the most important part in terms of beauty and performance is the projection refinement. Lateral crural overlay (LCO) is a common technique in rhinoplasty used to reduce nasal tip projection and increase nasal tip rotation. Given the important role of lower lateral cartilage (LLC) in the non-collapse of nasal external valve and air passage, it is necessary to evaluate the changes in nasal elasticity caused by surgery. The design of this quasi experimental study was self-control (before-after). Tip plasty was performed on twenty-four samples (12 cases of rhinoplasty) using LCO technique. To examine the elasticity, the strain index of each ala was measured by a mechanical device, invented by the author, before and after the operation. Out of 24 samples 12 were female and 12 were male. The mean strain index of nasal ala before and after the surgery was 0.24 ± 0.046 and 0.19 ± 0.040 respectively (P

Modification of the lower lateral cartilage complex is the sine qua non of modern rhinoplasty, and the open approach to rhinoplasty has expanded the number of techniques available to help achieve an aesthetically pleasing tip. The ideal tip has been described as having a diamond-shaped configuration, with the lateral points formed by the tip-defining points, the superior point by the supratip, and the inferior point by the columellar break point. Over the years, various techniques have been described to minimize isolation of the tip and to help achieve the ideal tip configuration: lateral crural strut grafts, alar contour grafts (i.e., rim grafts), alar strut grafts, subdomal grafts, and suturing techniques such as alar flaring sutures. The authors present their technique of the extended alar contour graft, which represents an evolution of the lateral crural strut graft and its marriage with the alar contour graft. Lateral crural abnormalities do not usually occur singularly, but rather are the result of an interplay of several factors. Nevertheless, the recurring theme of orientation and alar support to prevent isolation of the tip by extended alar grooves remains. Extended alar contour grafts are a versatile technique to optimize tip shape and orientation by combining the many positive attributes of lateral crural strut grafts and alar contour grafts.

The relapse of nasal deformity is a challenge for modern correction of cleft lip. A comprehensive understanding in the biomechanical perspective of both the formation and correction of the cleft lip nasal deformity would lead to improved stability of the corrective outcome. In this study, a finite element model of secondary cleft lip nasal deformity was constructed, on which two critical corrective maneuvers were mimicked in the form of force-loading. The intercrural suture was simulated by a force loaded at the intermediate crus of the alar cartilage directing anteriorly and medially, and the suture suspending the alar cartilage to the upper lateral cartilage was simulated by a force loaded at the lateral crus directing superiorly and medially. The equivalent von-mises stress and the total deformation consequent to different patterns of loading were captured. Our biomechanical analyses suggested that the intercrural suture at the nasal tip might be more effective in generating widespread morphological change than the suspension suture, but left much higher level of stress within the skin envelope if placed too high. Synergistic effect was observed between the two sutures in both the resultant deformation and stress. In addition, our simulations were partially supported by clinical photogrammetry data.

Revision rhinoplasties and saddle nose deformities usually require grafting for reconstruction. Between January 1, 2000, and January 1, 2017, autologous rib grafts were used in 127 secondary and tertiary rhinoplasty patients [(57/127 females) and (70/127 males)]. Osseous-cartilaginous rib grafts (OCRGs) were divided into three parts (i.e., 1/3 upper peripheral, 1/3 central, and 1/3 lower peripheral). The harvested OCRGs were also shaped as vertical strips using a number 11 scalpel blade. These OCRGs were shaped to form the L-strut cartilaginous graft (LSCGs), osseous-cartilaginous spreader grafts (OCSGs), osseous-cartilaginous onlay grafts, nasal valve grafts (NVGs), and lower lateral cartilaginous grafts (LLCGs). The upper peripheral portion of the rib was usually used as an onlay graft for dorsal reshaping. The shape of this part was minimally convex after being cut from the main graft, and the convex shape was very appropriate for use as an onlay graft. The middle portion of the graft that consisted of the osseous and cartilaginous structure was used for the OCSGs. The middle portion of the graft that contained only cartilage was used for the LSCGs, NVGs, and LLCGs. OCRGs were used for the dorsal, alar, septal, upper lateral, and columellar struts for all patients. OCSGs were used for all of the septal grafts to provide further stability. In the nasal valve failure patients, the rib cartilage was fixed onto the lower lateral and upper lateral cartilage and was sutured using polyglactin to improve nasal valve function. One edge of the graft was sutured over the septum, and the other edge was positioned against the maxillary crest to allow for air flow at the nasal valve. After an OCSG was sutured to the septum, a flat and smooth dorsum was shaped before the dorsal onlay graft was placed and fixed. The bone fragments of the grafts that consisted of spreader and onlay grafts were tied to the radix nasi bone without any space. After 6 months of follow-up, a minimally warping defect was apparent in 8 patients but none of these patients requested another surgery. The analysis of the questionnaire responses revealed that >90% of the patients were satisfied with the outcome of the procedure. Level of evidence IV 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 .

BACKGROUNDS The aims of the present study were to determine the exact level of separation of the upper lateral cartilage from the septal cartilage, and to classify the patterns of connection between the upper lateral cartilage and the lower lateral cartilage. METHODS We dissected and photographed 60 sides of noses; 18 specimens were sectioned and stained with Masson's trichrome. RESULTS The mean length of the connection between the upper lateral cartilage and septal cartilage was 16.1 mm. The mean level for separation of the upper lateral cartilage was 7.5 mm from the nasal bone. The pattern of connection between the upper lateral cartilage and lower lateral cartilage could be classified into five types: disconnection, end-to-end, overlap, scroll, and reverse scroll. CONCLUSIONS The results of the present study will be helpful for surgical procedures such as nasal hump reduction and nasal cartilage work and also provide information for the anthropometric study of the nose.

Craniofacial Neurofibromatosis is a benign but devastating disease. While the most common location of facial involvement is the orbito-temporal region, patients often present with significant mid-face deformities. We reviewed our experience with Craniofacial Neurofibromatosis from June 1981 to June 2011 and included patients with midface soft tissue deformities defined as gross alteration of nasal or upper lip symmetry. Data reviewed included the medical records and photobank. Over 30 years, 52 patients presented to and underwent surgical management for Craniofacial Neurofibromatosis at the Chang Gung Craniofacial Center. 23 patients (43%) demonstrated gross mid-facial deformities at initial evaluation. 55% of patients with lip deformities and 28% of patients with nasal deformities demonstrated no direct tumour involvement. The respective deformity was solely due to secondary gravitational effects from neurofibromas of the cheek subunit. Primary tumour infiltration of the nasal and/or labial subunits was treated with excision followed by various methods of reconstruction including lower lateral cartilage repositioning, forehead flaps, free flaps, and/or oral commissure suspension. Soft tissue deformities of the midface are very common in patients with Craniofacial Neurofibromatosis and profoundly affect overall aesthetic outcomes. Distinguishing primary from secondary involvement of the midface assists in surgical decision making.

In recent years, with the advent of 3-dimensional (3D) imaging techniques, it has become possible to objectively measure rhinoplasty results. However, few studies have used 3D imaging software to assess postoperative rhinoplasty results of the nasal tip.To analyze nasal tip volumes of patients with bulbous tips and measure postoperative nasal tip volume changes in patients who have undergone lower lateral cartilage (LLC) repositioning.A prospective study of patients with a preoperative diagnosis of bulbous nasal tip and cephalically oriented LLC as measured intraoperatively (with angles less than 30 degrees from the midline) who underwent rhinoplasty by a single surgeon and preoperative and postoperative 3dMD imaging at a university hospital.Rhinoplasty with LLC repositioning and preoperative and postoperative 3dMD system imaging. We also used 3dMD Vultus software for the analysis of nasal tip volume changes.Changes in nasal tip volume and LLC angle.Thirty-one patients met the inclusion criteria (25 women and 6 men; mean age, 33 years). Among these, there were 16 primary and 15 revision cases with a follow-up range of 1 to 19 months. Statistical tests included a paired t test on volume and angle changes as well as correlative and exploratory analyses to gain further insight into the analysis population over time. The change in the LLC angle after repositioning was found to be statistically significant. The mean decrease in volume on the right was 0.0254 mL, and the mean decrease on the left was 0.0249 mL. The mean total volume change was a decrease of 0.0503 mL. An exploratory analysis suggested that subjects with longer follow-up displayed a greater reduction in volume. Using 5 months as a cutoff, we found that the subgroup with longer follow-up displayed a mean total bilateral volume change of -0.07 mL compared with -0.03 mL in the subgroup with shorter follow-up.We found that LLC repositioning when used to address bulbous nasal tips and cephalically oriented LLCs leads to significant increase (preoperative to postoperative) in the angle of the LLC (to a more caudal orientation). We also found an overall trend of decreasing nasal tip volume throughout follow-up. Although not statistically significant, the overall decrease in volume is clinically meaningful when paired with favorable positioning of the LLC. Exploratory analyses suggest that treatment effect is consistent across sexes and that greater decrease in total volume might be found with longer follow-up.4.

Surgical strategies to refine the nasal tip should be conceived to address the lobule rather than just the domal extremity of this aesthetic region. The goal should be to create normal, stable anatomy. The anatomy of the tip cartilages is complex. Surgical strategies must consider the size, shape, position, and orientation of each crus including their relationships with the ipsilateral and contralateral crura of both lower lateral cartilage rings. Every surgical step has the potential for unintended as well as intended change. We favor as a first step fixation of the medial and lobular segments of the middle crura. The domes and lateral crura can then be addressed on a stable base. Suture placement must be precise with excess tightening avoided to prevent nonanatomical twists of the tip cartilage ring in part or whole. Consideration must be given to structural grafts to brace the crura and to correct convex lateral crura. These grafts should be incorporated within or deep to the tip cartilage framework to minimize visibility. It is the, contour, position, and orientation of the caudal margins of the middle and lateral crura which we think are a key component in achieving natural tip refinement.

Background Internal nasal valve (INV) collapse can contribute significantly to nasal obstruction and may be caused by upper lateral cartilage (ULC) collapse medially or laterally. Surgical techniques addressing INV collapse have focused more on treating the narrowed INV angle, with less consideration of the lateral INV area. This article describes a technique to improve INV patency both medially and laterally. This study analyzes the changes in minimal cross-sectional area (MCA) at the INV after graft placement and determines whether these changes are significantly different for normal versus narrow INVs. Methods Noses of six fixed cadavers were dissected by open rhinoplasty to release the ULCs from the septum. Upper lateral strut grafts were placed through subperichondrial pockets along the ULC undersurfaces and out over the piriform apertures into subperiosteal pockets. Grafts were secured to the dorsal septum. Acoustic rhinometry and nasal endoscopy were used to classify INVs before graft placement as narrow or normal and to assess changes at the INV after graft placement. Results Mean pregraft MCA was 0.58 cm2. Mean MCA percent increase after graft placement was 22%. By INV type, percent increases were 51% for narrow INVs and 1% for normal INVs. Mean increases in MCA after graft placement were statistically significant for the entire group and for narrow INVs, with increases of 0.10 cm2 (p = 0.03) and 0.22 cm2 (p = 0.004), respectively. Conclusion The upper lateral strut graft improved patency of cadaveric INVs, with statistically significant increases in the MCA most notable when placed for narrow INVs.

Dorsal hump reduction can lead to significant aesthetic and functional deformities with distortion of the dorsal aesthetic lines without first preserving and subsequently restoring proper position of the upper lateral cartilages. The senior author (R.J.R.) previously described the component dorsal hump reduction to preserve the integrity of the upper lateral cartilages, thereby avoiding routine use of spreader grafts. In this study, the authors introduce an efficient and reproducible technique they call the upper lateral cartilage tension spanning suture to reconstitute the upper lateral cartilages into anatomical position. The authors have found this technique to consistently achieve smooth and symmetric contour to the nasal dorsum and pleasing dorsal aesthetic lines.

Background Ala and nostril collapse are most raised complaints in secondary deformity of unilateral cleft patients. While a lot of techniques have been introduced so far, the purpose of this study was to evaluate the effectiveness of edge locked stitching between nostril ala and lateral cartilages with mucochondrial Z-plasty to correct the collapse in lower lateral cartilage in the ala and nostril shaping. Methods Fifty-seven patients with unilateral cleft nasal deformities were recruited. They all had primary surgery before and were left with nasal deformities. Based on the anatomic understanding, we operated on all the patients using edge locked stitching between nostril ala and lateral cartilages with a mucochondrial Z-plasty to correct the abnormal lateral collapse of nostril deformities. Results All the patients had an improvement in the shape of the ala and nostril immediately after the surgery. Follow-up at 6 months (or later) showed no severe relapse. Conclusion The edge locked stitching between nostril ala and lateral cartilages with mucochondrial Z-plasty is effective to correct ala and nostril deformities in unilateral cleft.

BACKGROUND The long nose with an inferiorly rotated tip commonly results from a discrepancy between tip support and the downward forces of long septum, long upper lateral cartilage, and elongated lower lateral cartilage. Although many techniques have been described for surgical correction, very few studies were designed to include patient-reported outcomes. OBJECTIVE The purpose of this study was to introduce our current management of long nose with drooping tips as well as to present the patient-reported outcomes of our case series of endonasal rhinoplasties. METHODS This study prospectively analyzed 121 patients who underwent rhinoplasty for the correction of long nose with drooping tips. Study participants completed both a baseline questionnaire before the rhinoplasty operation and a postsurgical patient questionnaire 12 months following the operation, including the European QOL Questionnaire and Rhinoplasty Outcomes Evaluation Questionnaire. RESULTS Mean values corresponding to the European QOL Questionnaire visual analog scale score significantly increased after surgery compared with baseline (P < 0.01). Mean values corresponding to self-care (P < 0.01), usual activities (P < 0.05), discomfort (P < 0.01), and anxiety (P < 0.01) showed significant decrease after surgery. A general and significant improvement of the mean Rhinoplasty Outcomes Evaluation Questionnaire scores by rhinoplasty increased from 20.14 ± 7.38 to 82.05 ± 12.8 (P < 0.01). CONCLUSIONS Resection of the caudal portion of upper lateral cartilage may correct aesthetic problems in patients with long nose with a drooping tip in which a reduction in the width and the length of middle third of the nose is required. This study suggested an efficient method for aesthetic correction of long nose with the improved patient-reported outcomes.

Summary Background There is no well-known indicator that can assist with a precise intranasal incision during open rhinoplasty on the caudal border of the lower lateral cartilage. However, the vibrissae-bearing area is clinically known as a good landmark for cartilage. The aim of this study was to investigate the features of the vibrissae-bearing area in relation to the lower lateral cartilage. Methods Twenty-four heminoses of fixed Japanese cadavers were dissected to clarify the anatomical location of the vibrissae-bearing area in relation to the lower lateral cartilage. Results The medial part of the vibrissae-bearing area was precisely located on the medial crus of the lower lateral cartilage. Via a transitional state at the dome, the lateral part was located cephalic to the lateral crus in a manner in which the vibrissae-bearing area was adjacent to the lateral crus (adjacent type) in 22 cases, whilst the vibrissae-bearing area overlapped the lateral crus to some extent (overlap type) in two cases. Conclusions The anatomical location of the vibrissae-bearing area in relation to the lower lateral cartilage is almost uniform, suggesting its utility as an open rhinoplasty incision landmark.

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.

Objectives/hypotheses: Nasal bone length is commonly referenced in the rhinoplasty literature. It has been suggested that short nasal bone length may predispose one to a greater risk of middle vault collapse after rhinoplasty. However, there are limited data available on what constitutes the normal dimensions of these pertinent structures of the nasal sidewall. In addition, no data exist on the gender and ethnic variability of such dimensions. This article reports on measurements of nasal bones and associated structures in adult Caucasian cadavers and their relationships to the nasal sidewall. Furthermore, this study assesses the validity of using surface measurements to approximate the true dimensions of the nasal sidewall structures. Methods: Using 37 adult cadavers, stable, 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 then evaluated relative to the direct measurements of dissected nasal bones and upper lateral cartilages in a subgroup of 14 cadavers. Results: For the subgroup, the average length Ainternal (nasal bone) was 24.57 mm; the average measured length Binternal (upper lateral cartilage) was 12.43 mm. Measurements for the subgroup obtained via external landmarks were 20.21 mm (Aexternal) and 15.67 mm (Bexternal), respectively. The relationship of the nasal bone internal length to the external measurement (A) was a ratio of 1.22:1, whereas the internal length of the upper lateral cartilage to the corresponding external measurement (B) was 0.79:1. Average external measurements for the total group were 20.43 mm for the nasal bone and 14.30 mm for the upper lateral cartilage. Conclusions: These data provide useful information to guide the surgeon in avoiding middle vault collapse postoperatively and when evaluating those patients with presurgical middle vault concerns. With less ability to support the upper lateral cartilages, short nasal bones can predispose an individual to middle vault collapse postoperatively.

Background Excess infratip lobule projection is often the result of deformities of the middle crus and lower lateral cartilage. The causes and correction of excess projection have not been well described. The classification of the deformities causing excess infratip lobule projection is defined and a surgical algorithm for addressing the infratip lobule is presented. Methods A retrospective review of primary rhinoplasties was combined with the use of a cadaver model to identify the causes of excess infratip lobule projection and develop an algorithm for its correction. Specific cases are presented to demonstrate the consistency and predictability of these techniques. Results The classification of excess infratip lobule projection is divided into intrinsic (i.e., long middle crus, wide middle crus, lower lateral malposition, and combination) and extrinsic causes (i.e., prominent septum). After correcting extrinsic causes, the algorithm progresses from medial to lateral, working from the medial crus to the lateral crus. Final refinement using transdomal sutures establishes the endpoint for infratip lobule projection and alar rim position when the cephalic and caudal edges (rotational orientation) of the lower lateral cartilage lie in the same plane. Conclusions A simple classification and logical algorithm are established to help rhinoplasty surgeons achieve aesthetic and consistent infratip lobule projection in cosmetic rhinoplasty. Establishing appropriate infratip lobule projection is essential for an aesthetic result in the lower third of the nose. The appearance of this complex area with the tip, columella, ala, and lobule has great importance in the final outcome in rhinoplasty. Clinical question/level of evidence Therapeutic, V.

Background There are many variables that influence nose tip harmony. Even in a rhinoplasty that appears successful in profile, one may see nostril asymmetries, alar retractions, or irregularities in the soft triangle, and patients express their dissatisfaction with these simple deformities. Objectives In this study, we define the ratio of caudal and cephalic excess of the lower lateral cartilage. We evaluate whether it is possible to eliminate nostril asymmetries and alar retractions by means of supporting the facet polygon with the help of a lower lateral cartilage auto-rim flap, a technique we have developed in our rhinoplasties. Methods The auto-rim flap was used successively on 498 primary rhinoplasty patients on whom the same surgeon operated between May 2013 and June 2015, performing marginal incisions. Results Of the 498 patients in the series, only 1 of the first 10 required a revision due to tip asymmetry related to the auto-rim flap. A minimal nostril asymmetry that did not require intervention occurred in 10 patients. In none of the patients could an increased alar retraction be seen postoperatively. All patients exhibited alar cartilage in the anatomically correct position. Conclusions With the auto-rim flap technique, a part of the caudal excess of the alar cartilage remains as a flap in the facet region; therefore, there is no need in the cephalic region to perform more of an excision than what is strictly necessary. Level of Evidence 4![Graphic][1] Therapeutic [1]: /embed/inline-graphic-1.gif

Demir, Ahmet/0000-0002-8820-3122 WOS: 000415085100083 PubMed: 27258706 Nasal tip support is critical to achieve a lasting result in rhinoplasty. In this article, the authors compared the effects of strut grafts (SG) and caudal septum-based nasal tip supporting techniques (CSB-T) in terms of reaching the desired tip projection. Included in this study were 40 patients (24 women and 16 men) who underwent primary open rhinoplasty via transcolumellar incision between January and June 2012. To achieve a good nasal projection, SG and CSB-T were used for 15 and 25 of these patients, respectively. Certain anatomic landmarks were identified on preoperative, simulative, and 1-year follow-up photos. With these landmarks, certain angular and proportional values were calculated. In the SG, the authors found no statistically significant difference in between simulative goals and postoperative results regarding bending angle. Postoperative nasolabial angle (NLA), tip angle, subnasal-tip/subnasal-radix (SnT/SnR) ratios were significantly lower than the simulation values; radix angle and supratip index values were significantly higher. In the CSB-T group, the authors found no statistically significant difference in between preoperative values and postoperative results regarding NLA, tip angle, bending angle, (SnT/SnR) ratio values. Postoperative supratip index and radix angle measurements were found to be significantly higher than the simulation values. With these findings, the authors concluded that CSB-T support is superior than the SG for supporting the nasal tip in noses that also need shortening in caudal length. In noses that do not need caudal shortening, nasal tip projection can again be supported by the caudal septum by just forming a bridge between lower lateral cartilage and quadrangular septum using a wider SG that mimics septal extension grafts.

BACKGROUND Many surgical technique have been described for repair of nasal septal perforations with different success rates. This study aimed to describe authors' surgical technique and discuss its results as well as those reported in the literature. METHODS Nineteen patients with nasal septal perforation were operated on between March 2009 and February 2015 at Istanbul University, Istanbul Medical Faculty. The technique described in this article, closure of the perforation with unilateral upper lateral cartilage inner mucoperichondrial flap and inferior meatal advancement flap is an alternative surgical technique. RESULTS Nineteen patients with symptomatic nasal septal perforation were operated with this technique. All surgical procedures were performed by the same surgeon. Neither intraoperative nor postoperative major complications were observed in any patients. Preoperative and postoperative symptom scores for nasal obstruction, epistaxis, nasal discharge, crusting, whistling, snoring, and olfactory loss as well as overall discomfort levels were compared using a visual analog scale. Complete closure of the perforation was achieved in 18 patients (95%). CONCLUSIONS Small and large perforations may be reliably closed with this technique. Also, this technique can be easily applied via closed or external approach.

tended to be the final surgery for patients with cleft lip and palate. The nasal tip and nostril asymmetries present in patients with unilateral cleft create difficulties for the definitive rhinoplasty. The typical findings contributing to these asymmetries are the retrodisplacement and underprojection of the dome, lateral slumping of the lower lateral cartilage (LLC), shortened columnella, and alar web and hooding. Herein, we present surgical pearls (Video) for performing a sliding chondrocutaneous flap, which incorporates the cleft lip incision, coupled with alar rim incision. Alar base plumping grafts are also often used. This technique can be successfully used as the primary rhinoplasty or as a revision rhinoplasty. In our practice, we perform primary rhinoplasty at the initial time of cleft repair at in patients 1 to 3 months of age and definitive rhinoplasty in teenagers, attempting to eliminate or minimize any intermediate surgical procedures to preserve available grafting material and prevent scarring. The sliding chondrocutaneous flap, or sliding cheilorhinoplasty, borrows tissue from the lip scar to improve projection of the dome and LLC position on the cleft side. The alar rim incision addresses alar and columnella hooding and creates better a contour of the nostril than a marginal incision. Both

The twisted nose is the most common deformity in noses, in our practice up to 50 %, but it presents a challenge to rhinoplastic surgeons as functional problems as well as aesthetic deformities often occur. The terminology used – deviated, twisted, crooked, asymmetric, scoliotic, and deflected – is confusing.

An oversized aural concha plays a significant role in prominent ear deformities and should be taken into consideration during preoperative examination. In the current study, we present a procedure known as the conchal sliding technique as an alternative to more disruptive methods. Twenty-four patients (9 females and 15 males; 47 ears in total) underwent a conchal sliding procedure between 2006 and 2010. During the surgery, a wide subperichondrial dissection is performed after a posterior elliptical incision. After the concha is exposed as a hemisphere, it is split along its long axis to reveal the medial and lateral cartilage segments. These segments are gently scrolled upon each other. Transposition of the lateral segment posteriorly to the medial segment replaces the whole ear toward the posterior direction. Three mattress sutures (4-0 polypropylene) reliably secure the repositioned and setback conchal bowl. If needed, an antihelix can be formed using neoconchal-scaphal mattress sutures. Median follow-up period was 24.3 months (range, 6-48 mo). A unilateral hematoma developed in 1 patient and an anterior step deformity occurred in another. No recurrence, infection, necrosis of the skin, distortion of the auditory canal, or formation of keloid was observed in any of the patients. The median cephaloauricular angle was measured as 46 degrees before the surgery and 26 degrees after the surgery, whereas the distance between the helix and the mastoid was 23 mm before the surgery and 11 mm after the surgery. All the patients were satisfied with the results. This technique provides stable and natural results by creating a safe neoconchal complex. It may be a safe and reliable solution to an oversized aural concha, enabling natural-looking and positive cosmetic results.

Hoof abscesses are probably the most common cause of acute severe lameness in horses encountered by veterinarians and farriers. Most affected horses show sudden, severe (acute) lameness; the degree of lameness varies from being subtle in the early stages to non-weight bearing. There is still debate between the veterinary and farrier professions as to who should treat a hoof abscess and the best method to resolve the abscess. Puncture wounds to the sole of the foot can introduce bacteria and debris to the solar surface of the distal phalanx and produce a fracture or a septic pedal osteitis.

INTRODUÇÃO: Diversas técnicas podem ser realizadas para melhorar a definição da ponta nasal como ressecção cartilaginosa, colocação de enxertos ou suturas. A realização de suturas na ponta nasal proporciona resultados estéticos satisfatórios com menor morbidade1-5. OBJETIVO: Avaliar a sutura intercrura lateral realizada na cartilagem lateral inferior, através de rinosseptoplastia endonasal por técnica básica sem delivery, para diminuição do ângulo de divergência domal no nariz caucasiano e consequente melhora na definição da ponta nasal. MÉTODO: Realizado estudo prospectivo com 64 casos nos quais foi confeccionada sutura no bordo cefálico da cartilagem lateral inferior na junção entre a cúpula e crus lateral, utilizando-se fio P.D.S. (Polydioxanorie®) incolor 4"0" com agulha curva cortante. RESULTADO: Foram analisadas e comparadas as fotos do pré - operatório e do pós -operatório com 6 meses de evolução. Em todos os casos foi atingida uma melhora na definição da ponta através da sutura intercrura lateral. CONCLUSÃO: A sutura intercrura lateral da cartilagem lateral inferior mostrou ser factível para uma melhor definição da ponta no nariz caucasiano podendo ser realizada por rinoplastia endonasal sem delivery. INTRODUCTION: Several techniques can be performed to improve nasal tip definition such as cartilage resection, tip grafts, or sutures. OBJCTIVE: To evaluate the outcome of lateral intercrural suture at the lower lateral cartilage by endonasal rhinoplasty with a basic technique without delivery in decreasing the angle of domal divergence and improving the nasal tip definition. METHOD: This prospective study was performed in 64 patients in which a suture was made on the board head of the lower lateral cartilage in the joint between the dome and lateral crus, using polydioxanone (PDS) with sharp, curved needle. RESULTS: In all of the cases, better definition of the nasal tip was achieved by intercrural suturing for at least 6 months postoperatively. CONCLUSION: Lateral intercrural suture of the lower lateral cartilage provides improved nasal tip definition and can be performed by endonasal rhinoplasty without delivery in the Caucasian nose.

UNLABELLED There are a variety of techniques that can be used to enhance or improve the nasal tip. These techniques often use suture techniques and invisible grafts to achieve the desired result. The former methods have been well described throughout the literature. Among the latter techniques, the columellar strut remains a popular and effective form of an invisible graft in rhinoplasty. The purpose of this article is to define the role of the columellar strut graft, describe how to perform it correctly in rhinoplasty, provide a clinical algorithm for its application, and detail a 15-year retrospective analysis of the senior author's (R.J.R.) experience. Previous references to the importance of the columellar strut graft in rhinoplasty have been described; however, none has formally defined its singular importance in both primary and secondary open rhinoplasty. This article details the role of the columellar strut and its relationship to nasal tip projection and lower lateral cartilage symmetry with an explanation of methods for improving each. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Background: Success or failure of rhinoplasty depends mainly on the awareness of the surgeon with the construction of the nasal cartilaginous framework and the knowledge of the morphology and different dimensions of these cartilages. The current study aimed at evaluation of the morphology of the nasal cartilages and to address their different measurements as well as observation of anatomical variations of these cartilages and elucidation of their implications in rhinoplasty. Materials and methods: Thirty adult human cadaveric noses, males and females aged 20–70 years were used in the current study. The specimens were dissected; cartilages were exposed and examined morphologically for shape, parts and attachments. Different nasal cartilage measurements were done. Results: The examination of nasal cartilage revealed that the mean length of upper lateral cartilage was variable. The mean width and thickness were 12.8 ± 1.29 mm and 1.34 ± 0.14 mm, respectively. The mean length, width and thickness of alar cartilage were assessed. Angle of divergence was observed to be 23–44°. Statistically, there were no significant differences between genders. Conclusions: Data obtained from this study confirmed the anatomical varia­tions of the nasal cartilages among the Egyptians and confirmed the differences with several ethnic groups. This has important surgical implications giving the attention required during different techniques in rhinoplasty in order to maintain dorsal aesthetic lines of the nose and proper respiratory function.

The sulcus angle has been widely used in the literature as a measure of trochlear morphology. Recently, lateral trochlear inclination and trochlear angle have been reported as alternatives. The purpose of this study was to determine the association between measures of trochlear morphology and patellofemoral joint (PFJ) cartilage damage and bone marrow lesions (BMLs). 907 knees were selected from the Multicenter Osteoarthritis Study, a cohort study of persons aged 50-79 years with or at risk for knee OA. Trochlear morphology was measured using lateral trochlear inclination, trochlear angle, and sulcus angle on axial MRI images; cartilage damage and BMLs were graded on MRI. We determined the association between quartiles of each trochlear morphology level with the presence or absence of cartilage damage and BMLs in the PFJ using logistic regression. The strongest associations were seen with lateral trochlear inclination and lateral PFJ cartilage damage and BMLs, with knees in the lowest quartile (flattened lateral trochlea) having more than two times the odds of lateral cartilage damage and BMLs compared to those in the highest quartile (p

Tip surgery remains the most difficult part of rhinoplasty in Asian patients because of the lower lateral cartilage characteristics and thick skin. The objective of this study was to evaluate the multilayer cartilaginous tip-grafting technique used for tip refinement in Korean patients undergoing rhinoplasty.Case series with chart review.Academic tertiary care medical center.A retrospective study of 99 Korean patients who underwent open rhinoplasty involving multilayer cartilaginous tip-grafting for tip refinement was performed. Autologous septal, conchal, costal, or homologous costal cartilage, or a combination of these materials was used as grafting materials. Preoperative and postoperative photographs were reviewed for objective and subjective assessment of aesthetic outcomes.Among patients, 7 had undergone previous rhinoplasty (7.1%), and removal of the previously placed silicone graft was required in 5 patients (5.1%). Two (6.7%), 3 (61.5%), 4 (28.8%), and 5 (3.0%) layers of cartilaginous graft were used. Postoperative aesthetic outcomes were graded as excellent in 63.6%, fair in 28.3%, and no change/worse in 8.1% of cases. Preoperative and postoperative objective measurements showed that the procedure resulted in increased nasal tip projection (0.52 ± 0.06 vs 0.57 ± 0.05; P.05) and improved nasolabial angle (92.98° ± 9.95° vs 95.34° ± 8.20°; P.05). The overall complication rate was 12.1%, and 8 patients required revision surgery (8.1%). Complications included infection (5.1%), visible graft contour (1.0%), nostril deformity (1.0%), overprojection (2.0%), and visible hypertrophic scar at the marginal incision site (3.0%).The multilayer cartilaginous tip-grafting technique was found to be effective for aesthetic refinement of the nasal tip when used in rhinoplasty for Korean patients.