Vertical lobule division in rhinoplasty: maintaining an intact strip

Composite Tissue Columella Wedge Excision for Nasal Tip Overprojection

BACKGROUND

The overprojected nasal tip is a challenge in facial surgery. Although several techniques are available, none has been proven to be superior. The aim of this study was to introduce a novel approach to overcome nasal tip overprojection and to evaluate its safety and efficacy.

METHODS

All patients with protruding nasal tip who underwent correction by means of a novel columella wedge technique were included in this study. In addition to detailed description of the novel surgical approach, its efficacy was analyzed by comparison of preoperative and postoperative nose dimensions. In addition, patients were examined during follow-up, and complication and revision rates were determined.

RESULTS

Forty-two patients were included in this study. Columella wedge technique involved resection of a 2- to 5-mm section of the middle part of the columella. Postoperatively, nose projection and length decreased by 9 and 12 percent, respectively. The relation between projection and length of the nose changed from 0.68 preoperatively to 0.61 postoperatively. This difference was statistically significant (p = 0.002). After a mean follow-up of 28 months (range, 6 to 144 months), revision operations were necessary in seven patients (16.6 percent). No instabilities, impairment of breathing, or other complications occurred.

CONCLUSION

The introduced columella wedge technique is efficient and safe for correction of the overprojected nasal tip.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Classification of Angulation Deformities of Lower Lateral Cartilages and Their Restoration

BACKGROUND

Shape of the tip is supplied by lower lateral cartilages (LLC) which are divided into 3 crura each composed of 2 segments divided by junction lines (JL). Tip restoration becomes more complicated with the presence of angulation deformities (AD) over LLC. It is aimed to classify AD based on their relationship to JL, to clarify their causes of the formation and to discuss restoration techniques for each of them.

MATERIAL AND METHODS

Between 2016 and 2018, 375 primary rhinoplasties have been performed. All types of the AD have been retrospectively determined, renamed. Six different types of AD have been encountered in this series. Four of AD (types A, B, C, and D) have been located over JL and 2 of AD (types S and T) have not been located over JL.

RESULTS

Type-A AD diverging the footplates were observed in 9 patients, type-B AD resulting in a boxy-nose were observed in 18 cases, type-C AD resulting in acute angulation of the dome at the medial genu were observed in 4 patients, type-D AD resulting in a pinched tip and concave alar wings were observed in 6 patients, type-S AD resulting in a weak, and short columella were observed in 5 patients, type-T AD that creates a bulge over ala was observed just in 1 patient in our series. The total number of patients with AD was 39 (10.4% of all cases).

CONCLUSION

Classification of AD over LLC based on their relationship to certain JL provides ease for recognition of these deformities and immediate per-operative planning for their restoration.

Decreasing nasal tip projection in rhinoplasty

BACKGROUND

Decreasing nasal tip projection is occasionally required in rhinoplasty and requires a working knowledge of nasal support and function. Equally important is an understanding of the evolution to a more conservative and incremental approach when decreasing nasal tip projection. Such a conservative approach reserves the most aggressive and precarious maneuvers to be used only when absolutely required.

METHODS

The authors review the history and evolution of techniques regarding decrease in nasal tip projection. Anatomy of the nasal tip with focus on tip support structures is reviewed. Distinguishing between pseudo-overprojection and true overprojection of the nasal tip is discussed. Methods of diagnosing nasal tip projection are reviewed and a suggested surgical approach is presented.

RESULTS

Reduction of nasal tip projection requires a thorough knowledge of relevant anatomy and tissue interplay. Although a variety of techniques and algorithms exist in addition to those recommended in this article, the goal should be an incremental approach with constant reassessment. Tip truncation is rarely if ever indicated and is often associated with eventual contour deformity.

CONCLUSION

The described approach in this article has been proven reliable for the vast majority of patients undergoing rhinoplasty with the overprojected nose.

Rhinoplasty: panel discussion

Should one use an open or closed rhinoplasty approach? How appropriate is the endonasal approach in modern-day rhinoplasty? Should the tip lobule be divided or preserved? Are alloplastic implants inferior to autologous implants? Does release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid one-third nasal pinching in reduction rhinoplasty? Over past 5 years, how have rhinoplasty techniques and approaches evolved?

Primary nasal tip surgery: a conservative approach

BACKGROUND

Rhinoplasty and rhinoseptoplasty are very important and complex surgical procedures because the nose plays a pivotal aesthetic role in the face and an important functional role in breathing. Mild bulbous, plunging, undefined tips are very common, and tip refining and repositioning often are required surgical procedures.

METHODS

For 97 selected patients, the authors performed their personal technique consisting of a transcartilaginous approach, incomplete vertical interruption, and retrograde undermining of the lower lateral cartilages to improve tip projection and definition. The five aspects analyzed were nasal tip symmetry, nostril symmetry, tip projection, tip definition, and appearance of the nasal tip only. Each parameter was assessed using pre- and postoperative quantification according to a visual analog scale. Postoperative evaluation was performed during a mean follow-up period of 1 year.

RESULTS

The results at 1 year showed high rates of improvement in tip definition (mean, 7.9±2.4) and nasal tip only evaluation (mean, 6.5±3.1). The patients reported an improvement in nasal tip symmetry (mean, 4.2±3.2), nostril symmetry (mean, 4.5±4.1), and tip projection (mean, 5.8±2.9).

CONCLUSIONS

This simple, safe, and effective technique is proposed for mild bulbous, plunging, undefined, and hypoprojected tips.

Use of the Goldman technique to correct both the overprojected and the broad nasal tip

BACKGROUND

Tip surgery probably is the most challenging objective in modern rhinoplasty. The Goldman technique, despite its 50 years of history and its many variations proposed in the past, still remains a powerful tool for the surgeon who has to deal with an overprojected or broad nasal tip.

METHODS

A retrospective review was performed for all the patients who underwent surgery with the Goldman technique by the senior author from 2004 to 2009 for correction of the broad or overprojected nasal tip. The clinical and pathologic findings of these patients were reviewed, and an independent observer evaluated the pre- and postoperative photos of the patients using five parameters: projection, rotation, symmetry, shape, and distance of the tip-defining points. The evaluation was performed using a scale of -1 to +1 for each of the five parameters.

RESULTS

Of the 205 patients who underwent the technique, 115 (56%) were patients with overprojected tips, and 90 (44%) were patients with broad (boxy) tips. A total of 189 cases (92.2%) involved primary rhinoplasties, and 16 cases (7.8%) involved revision. The mean follow-up period was 3 years (range, 1-5 years). During this period, complications were observed in five patients (2.4%), who underwent revision rhinoplasty with a successful result. The average score for the five parameters already mentioned for primary rhinoplasties according to the scale of -5 to +5 (resulting from the summation of all the parameters) showed a significant postoperative improvement (score, +4.3). The revision rhinoplasties showed significant improvement as well (score, +4.5).

CONCLUSION

The Goldman technique is safe when performed by experienced surgeons and according to specific indications. This conclusion is indicated by the low rate of complications in the large series of patients in this study. When performed correctly, the Goldman technique provides a long-term aesthetic, functional, and natural result, which is the goal of modern functional rhinoplasty.

[The sliding technique : a precise method for treating the overprojected nasal tip]

BACKGROUND

The aim of the present report is to demonstrate the sliding technique as a reliable and exact method to treat the overprojected nasal tip.

METHODS

Between March 2003 and April 2008 we treated 271 patients (198 females, 73 males) using the sliding technique for isolated tip hypertrophy (n=88), rhinomegaly (n=146), asymmetry of the nasal tip (n=29) and ptosis with malformation of the alar cartilages (n=8).

RESULTS

Medial sliding was performed in 100 patients, lateral sliding in 121 patients, and combined lateral and medial sliding in 12 patients. In total, 18 patients needed additional skin resection at the columella. After an average follow-up period of 8.4 months 77.1% of the patients (n=209) rated the result as "very good", 21.1% (n=57) as"good" and 1.8% (n=5) patients were"unsatisfied". Only 1.8% (n=5) had to be revised due to nasal tip projection. A retrospective study of our first 80 patients showed an average reduction in projection of around 11%.

CONCLUSION

The sliding technique is a precise and effective method to treat the overprojected nasal tip.

Complications in rhinoplasty

The surgical maneuvers employed in aesthetic rhinoplasty can result in unforeseen structural complications that lead to an unsatisfied patient. Many of these problems arise years after the primary surgery and include both aesthetic and functional losses. Contemporary rhinoplasty should always be designed with long-term perspective and an eye on possible untoward outcomes. This article discusses the anatomic and physiologic basis of rhinoplasty complications with a focus on primary rhinoplasty principles that will prevent their formation.

The sliding technique: a method to treat the overprojected nasal tip

BACKGROUND

This report aims to demonstrate the advantages of the sliding technique for reducing an overprojected tip.

METHODS

In this study 271 patients (201 females, 70 males) were treated using this technique. It was used for isolated tip hypertrophy (N = 93) and combined deformities (N = 147).

RESULTS

A medial sliding was performed in 109 patients, a lateral in 125 patients, and a combined lateral and medial sliding was used in 9 patients. Twenty patients needed additional skin resection at the columella. Follow-up of our first 80 patients showed an average reduction of around 11%. Only one patient of 80 in this study had to be revised.

CONCLUSION

The sliding technique is safe and reliable as well as a logical and effective technique to deproject the nasal tip.

Intermediate crural overlay in rhinoplasty: a deprojection technique that shortens the medial leg of the tripod without lengthening the nose

OBJECTIVE

To review the indications for, surgical techniques of, and results of intermediate crural overlay of the alar cartilages in rhinoplasty.

DESIGN

Prospective study of patients undergoing intermediate crural overlay of the lower lateral cartilages. The setting was a facial plastic surgery private practice. Patients included 10 primary rhinoplasty patients and 1 revision rhinoplasty patient who underwent intermediate crural overlay of the lower lateral cartilages. The main outcome measures were postoperative photographs and patient records, which were reviewed for tip projection and rotation, preservation of the double break, bossae, and knuckling.

RESULTS

Intermediate crural overlay decreased projection in all 11 patients and increased the nasolabial angle in 7 patients. One patient had no change in the nasolabial angle, and 3 patients had counterrotation of 1 degrees , 3 degrees , and 4 degrees . A postoperative physical examination revealed that no patient had developed bossae, tip asymmetries, or knuckling. In addition, the double break was maintained in all the study patients.

CONCLUSIONS

Intermedial crural overlay is a reliable technique for achieving tip deprojection. Overall, the nasolabial angle is maintained (although in 3 patients, clinically insignificant counterrotation did occur). In addition, the length of the intermediate crura is reduced, but the double break is preserved. In the group of patients with thin skin and tip overprojection secondary to overdevelopment of the lower lateral cartilages, intermediate crural overlay achieves tip deprojection while controlling the nasolabial angle and preserving the natural curvature of the dome.