Controlling Nasal Tip Projection and Rotation with New Composite Septocolumellar Flap Approaches

BACKGROUND

Rhinoplasty is one of the most common and challenging surgeries in the field of aesthetic surgery. For obtaining an aesthetically pleasing nose, it is extremely important to control nasal tip projection and rotation as much as possible. Since the last decade, septocolumellar suture techniques have been most frequently used for modifying and controlling nasal tip rotation and projection and for obtaining a better columellar-labial angle during rhinoplasty. In the present study, the author has described 10 different approaches using composite septocolumellar flaps with the aim of obtaining better outcomes, such as the control of nasal tip projection and rotation, in addition to obtaining better tip refinement.

METHODS

The records of 68 patients were included in the present study based on the inclusion and exclusion criteria. Ten composite septocolumellar flap approaches were followed by the same surgeon.

RESULTS

The initial median Rhinoplasty Outcome Evaluation score was 60.5 points; the score increased to 92.5 points at 12 months after the surgery (p < 0.001). Satisfaction was excellent in 87.5 percent of the patients. The patients were also evaluated in terms of functionality. Their patency scores increased from 6.0 to 9.0 (out of 10) after a 12-month follow-up (p = 0.001).

CONCLUSIONS

The technique has the following advantages: control of nasal tip projection and rotation, fixation of mild deviations, and shortening of the nose with better aesthetic and functional outcomes. Furthermore, because the septocolumellar region is completely protected and remains solid, a dynamic nasal tip is obtained. Surgeons will be able to choose the most suitable approach when a composite septocolumellar flap is needed.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Dorsal Augmentation

To manage the deficient nasal dorsum, a thorough knowledge of dorsal augmentation techniques should be mastered by the rhinoplasty specialist. Indications for dorsal augmentation may arise in both primary and revision rhinoplasty presentations. To direct operative planning, a complete facial analysis, noting the importance of maintaining overall nasofacial balance, is essential. An array of techniques, including autologous and nonautologous (ie, allogeneic and synthetic) sources, have been used globally-each carrying its own advantages and disadvantages. The authors believe autologous grafts to be the optimal source for dorsal augmentation because of their biocompatibility and ability to produce natural and long-lasting outcomes.

Toward tissue-engineering of nasal cartilages

Nasal cartilage pathologies are common; for example, up to 80% of people are afflicted by deviated nasal septum conditions. Because cartilage provides the supportive framework of the nose, afflicted patients suffer low quality of life. To correct pathologies, graft cartilage is often required. Grafts are currently sourced from the patient's septum, ear, or rib. However, their use yields donor site morbidity and is limited by tissue quantity and quality. Additionally, rhinoplasty revision rates exceed 15%, exacerbating the shortage of graft cartilage. Alternative grafts, such as irradiated allogeneic rib cartilage, are associated with complications. Tissue-engineered neocartilage holds promise to address the limitations of current grafts. The engineering design process may be used to create suitable graft tissues. This process begins by identifying the surgeon's needs. Second, nasal cartilages' properties must be understood to define engineering design criteria. Limited investigations have examined nasal cartilage properties; numerous additional studies need to be performed to examine topographical variations, for example. Third, tissue-engineering processes must be applied to achieve the engineering design criteria. Within the recent past, strategies have frequently utilized human septal chondrocytes. As autologous and allogeneic rib graft cartilage is used, its suitability as a cell source should also be examined. Fourth, quantitative verification of engineered neocartilage is critical to check for successful achievement of the engineering design criteria. Finally, following the FDA paradigm, engineered neocartilage must be orthotopically validated in animals. Together, these steps delineate a path to engineer functional nasal neocartilages that may, ultimately, be used to treat human patients. STATEMENT OF SIGNIFICANCE: Nasal cartilage pathologies are common and lead to greatly diminished quality of life. The ability to correct pathologies is limited by cartilage graft quality and quantity, as well as donor site morbidity and surgical complications, such as infection and resorption. Despite the significance of nasal cartilage pathologies and high rhinoplasty revision rates (15%), little characterization and tissue-engineering work has been performed compared to other cartilages, such as articular cartilage. Furthermore, most work is published in clinical journals, with little in biomedical engineering. Therefore, this review discusses what nasal cartilage properties are known, summarizes the current state of nasal cartilage tissue-engineering, and makes recommendations via the engineering design process toward engineering functional nasal neocartilage to address current limitations.

Complications associated with autologous rib cartilage use in rhinoplasty: a meta-analysis

IMPORTANCE

Although autologous rib cartilage is a preferred source of graft material in rhinoplasty, rib cartilage for dorsal augmentation has been continuously criticized for its tendency to warp and for high donor-site morbidities. However, no meta-analysis or systemic review on complications associated with autologous rib cartilage use in rhinoplasty has been conducted.

OBJECTIVE

To carry out a systematic review and a meta-analysis of available literature to evaluate complications regarding autologous rib cartilage in rhinoplasty.

DATA SOURCES

The studies reporting complications associated with the autologous rib cartilage use in rhinoplasty were systematically reviewed by searching the MEDLINE, PubMed, and Embase databases for sources published from 1946 through June 2013.

STUDY SELECTION

The selected articles included clinical studies conducted with at least 10 patients and at least 1 postoperative long-term complication or donor-site morbidity in rhinoplasty. Excluded were nonhuman studies; review articles; case reports; abstracts; and reports of nasal reconstruction as indication for surgery, use of homologous rib cartilage, and diced or laminated methods.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently reviewed all studies and extracted the data using a standardized form. A meta-analysis was performed using a random-effects model.

MAIN OUTCOMES AND MEASURES

Number of patients; follow-up duration; and rates of complication, donor-site morbidity, and revision surgery. Also noted were study authors and year of publication.

RESULTS

Ten studies involving a total 491 patients were identified. Mean follow-up across all studies was 33.3 months. In meta-analysis, the combined rates were 3.08% (95% confidence interval [CI], 0%-10.15%) for warping, 0.22% (95% CI, 0%-1.25%) for resorption, 0.56% (95% CI, 0%-2.61%) for infection, 0.39% (95% CI, 0%-1.97%) for displacement, 5.45% (95% CI, 0.68%-13.24%) for hypertrophic chest scarring, 0% (95% CI, 0%-0.32%) for pneumothorax, and 14.07% (95% CI, 6.19%-24.20%) for revision surgery.

CONCLUSIONS AND RELEVANCE

The overall long-term complications and donor-site morbidity rates associated with autologous rib cartilage use in rhinoplasty were low. Warping and hypertrophic chest scarring showed relatively higher rates, warranting a surgeon's attention. Because a limited number of studies and patients were eligible, and consistent definitions of complications were lacking in this meta-analysis, future studies with a larger series of patients and objective outcome measurements are needed to obtain more reliable results.

LEVEL OF EVIDENCE

4.