Management and aesthetic results of support grafts in saddle nose surgery

Aesthetic Outcome of Primary Rhinoplasty of Saddle Nose Deformity in Naso-Orbital Ethmoidal Fractures in Asian Patients

BACKGROUND

Saddle nose deformity following naso-orbital ethmoidal (NOE) fractures remain a challenging problem for the reconstructive surgeon. Early reduction and internal fixation allow for fracture stabilization but is unable to address the problem of the depressed nasal dorsum, especially after soft tissue shrinkage. The aim of this study is to evaluate the outcome of primary rhinoplasty in patients with NOE fractures.

MATERIALS AND METHODS

From 2016 to 2019, 9 patients presented to our department with NOE fractures complicated by saddle nose deformity underwent primary nasal reconstruction at the time of their fracture fixation. Life size (1:1) frontal and lateral postoperative photographs were taken. Three objective measurements were made, including the nasofrontal angle, tip projection, and radix projection. These measurements were compared between normal persons (group 1), preoperative patients (group 2), and postoperative patients (group 3). Nose aesthetic assessment was carried out via a panel assessment using a Visual Analog Scale of 5. Patient satisfaction was further assessed subjectively by the patient themselves using the Visual Analog Scale.

RESULTS

When comparing group 3 to 2, a significant reduction in the nasofrontal angles was found with an accompanying increase in the radix and tip projection ( P <0.05). No statistical significance between normal persons and postprimary rhinoplasty patients was noted between groups 1 and 3. Average patient satisfaction scored 3.86±1.07 compared with 3.63±0.84 by laypersons and 4±0.77 by specialists' panel.

CONCLUSION

Primary nasal reconstruction may be an alternative method for achieving optimum results following NOE fractures preventing the development of secondary saddle nose deformity with a shortened nose which may potentially be more difficult to correct.

[Options for reconstruction after injuries in the head and neck region]

Reconstruction of lesions in the head and neck region must be both functionally and esthetically adequate, as the exposed anatomic position can easily lead to social stigmatization after injury. Distortion of symmetry, e.g., by a crooked nose, enophthalmos, or a (partial) amputation of the outer ear, is easily visible. On the other hand, limitations to nasal breathing and olfaction or diplopia may significantly reduce quality of life, and restoration of form and function continues to be challenging. This review discusses the treatment options for trauma of the external nose and the lateral midface, including the orbital floor and the auricle.

Optimizing the Use of Autografts, Allografts, and Alloplastic Materials in Rhinoplasty

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the autologous graft options available to the rhinoplasty surgeon, including septal cartilage, auricular cartilage, costal cartilage, and bone. 2. Understand the autograft and allograft options available to the rhinoplasty surgeon, including cadaveric costal cartilage, silicone, Medpor, and Gore-Tex. 3. Identify the ideal situations to use each of these implant materials. 4. Understand the advantages and disadvantages of the different autografts, allografts, and implants in rhinoplasty.

SUMMARY

This review focuses on the graft options available to the modern rhinoplasty surgeon. Autologous options are varied in the quality of cartilage harvested and the morbidity of the donor site. In addition, surgeons should understand the allograft options should autologous grafting be unfeasible or undesirable. New technological advances in processing of allograft cartilage makes this an attractive secondary option.

Current Practices in Dorsal Augmentation Rhinoplasty

BACKGROUND

Dorsal augmentation rhinoplasty addresses the aesthetic and functional impairments caused by a deficient nasal dorsum. Augmentation rhinoplasty can be performed using a variety of different surgical techniques and grafting materials that all have distinct advantages and disadvantages.

METHODS

Grafting materials have unique characteristics, uses, and safety profiles. A detailed overview of various grafting materials and their uses, risks, and benefits is provided.

RESULTS

Autologous grafting materials include septal cartilage, auricular cartilage, and costal cartilage. These donor sites can provide various amounts of en bloc or diced cartilage. Alternatively, bone may be used when strong structural stability is required, and soft tissue may be used to fill mild to moderate defects. Homologous grafts (e.g., irradiated and nonirradiated rib) and acellular dermal matrices are alternatives to autologous graft with many similar advantages and no need for an additional surgical site. Lastly, alloplastic implants may be successfully used for dorsal augmentation if both patient and surgeon understand their associated risks.

CONCLUSION

To perform successful dorsal augmentation, surgeons should be familiar with the wide variety of operative approaches and augmentation materials that are currently available and understand their risks, benefits, and uses.

Saddle nose: classification and therapeutic management

INTRODUCTION

The understanding and treatment of saddle nose have always been a surgical challenge. The authors propose a three-stage classification of this deformity as well as a treatment strategy adapted to each case.

MATERIALS AND METHODS

A retrospective study was carried out on 25 patients with saddle nose. After defining the three stages of saddle nose: minimal, moderate and major, the authors describe the treatment protocol adopted for each stage.

RESULTS

This series comprised 3 cases of minimal saddle nose, 17 cases of moderate saddle nose and 5 cases of major saddle nose. Minimal saddle nose was treated by extracorporeal rhinoplasty, an inverted U-shaped conchal graft was used to treat moderate saddle nose, and costal cartilage was used to reconstruct major saddle nose. Surgical approaches varied according to the technique adopted. Surgical revision was never required.

CONCLUSION

Saddle nose is a classical condition in facial reconstructive surgery. The proposed treatment strategy is based on detailed analysis of the clinical signs, resulting in a graduated solution adapted to each clinical case according to the severity of the deformity.

Reconstruction of internal nasal valve, septum, dorsum, and anterior structures of the nose in a single procedure with a molded bone graft: the sail graft

Excessive surgical removal or traumatic loss of the tissues supporting the nasal roof can result in the "saddle nose" deformity. It involves both cartilage and bone deficiencies. Two main resources are used to reconstruct this difficult deformity: autogenous bone and cartilage grafts and alloplastic materials. This study presents the reconstruction of the dorsum, septum, internal nasal valve, and anterior structures and the tip of the nose using a block of molded autogenous bone graft. We called it the "sail graft," because it looks like a sail from a lateral view. The mast of the sail is oriented in a superior-to-inferior direction, beginning in the frontonasal region to the tip of the nose to form a straight, well-rounded dorsum. The longest postoperative follow-up of 13 cases is now 10 years; the median follow-up is 2 years. The results have been satisfactory.

Influence of age on rhinoplasty outcomes evaluation: a preliminary study

BACKGROUND

The aim of this study was to evaluate the satisfaction of patients who underwent rhinoplasty by using the Rhinoplasty outcomes evaluation (ROE) questionnaire and determine the influence of patient age on the outcomes.

METHODS

We conducted a longitudinal study to assess patients' pre- and postoperative degrees of satisfaction with their results. The study was done at a tertiary-care medical center. The ROE questionnaire was applied twice in the same visit and aimed at measuring the patient's satisfaction in both pre- and postoperative moments.

RESULTS

The initial sample of this study was composed of 112 patients, 61 of whom have answered the ROE questionnaire. A mean difference of 50.5 (P < 0.0001) was observed between the pre- and postoperative satisfaction scores. No statistically significant difference was observed on the mean difference between pre- and postoperative satisfaction scores (CHANGE) according to sex (P = 0.673), the follow-up time period (P = 0.629), or the kind of surgical procedure (P = 0.904). The mean postoperative score of the <30-year-old group was lower than the mean of 30 to <50-year-old (P < 0.003) and ≥50-year-old groups (P < 0.009).

CONCLUSION

The ROE questionnaire is a tool for evaluating the outcomes of different surgical indications for correcting nasal deformities. The kind of surgical procedure had no influence on the mean difference between pre- and postoperative satisfaction scores. By using this tool we found that the younger age group reported lower postoperative satisfaction scores than older patients.

Correction of major saddle nose deformities with nasomaxillary depression using an intraoral and external open rhinoplasty approach

Nasomaxillary depression, which may be seen with major saddle nose deformities, especially as a sequel to childhood nasal trauma, generally is overlooked during management of the saddle nose. To handle both the saddle nose deformity and nasomaxillary depression, the authors used a one-stage intraoral and external open rhinoplasty approach for 12 patients. Lateral nasal osteotomies and correction of midface retrusion with crescent-shaped autogenous rib cartilage grafts were performed through two bilateral intraoral gingivobuccal incisions. The external open rhinoplasty approach was used for the correction of the saddle nose deformities. The mean follow-up period after the surgery was 2 years (range, 1-3.5 years). The correction of nasal tip depression resulting from midface retrusion was evaluated by lateral cephalometric radiographs. The mean movement of the nasal tip anteriorly in the sagittal plane 1 year after the operation was 5.5 mm (range, 4-7 mm). The functional and aesthetic results were satisfactory for all the patients. As the findings show, the intraoral part of the approach provides a route for the placement of cartilage grafts to correct the depressed nasal tip, augment the paranasal area, and provide support to the lateral alar bases and the controlled low-to-low lateral osteotomies. The external part of the approach provides correction of the saddle nose deformity.

Current status of grafts and implants in rhinoplasty: part I. Autologous grafts

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the challenges in restoring volume and structural integrity in rhinoplasty. 2. Identify the appropriate uses of various autografts in aesthetic and reconstructive rhinoplasty (septal cartilage, auricular cartilage, costal cartilage, calvarial and nasal bone, and olecranon process of the ulna). 3. Identify the advantages and disadvantages of each of these autografts.

SUMMARY

This review specifically addresses the use of autologous grafts in rhinoplasty. Autologous materials remain the preferred graft material for use in rhinoplasty because of their high biocompatibility and low risk of infection and extrusion. However, these advantages should be counterbalanced with the concerns of donor-site morbidity, graft availability, and graft resorption.

Nasal reconstruction of the leprosy nose using costal cartilage

Leprosy is a chronic granulomatous infection of the skin and peripheral nerves that often leads to gross deformation of the nasal skeleton and subsequent formation of a saddle-nose deformity. Reconstruction of the nose following Mycobacterium leprae infection has challenged surgeons for centuries. As a result, a number of different techniques have been attempted with varying outcomes. This article describes the case and surgical treatment of a 37-year old female who presented with a subtotal nasoseptal perforation and saddle-nose deformity secondary to previous infection with leprosy. Reconstruction was achieved via an open septorhinoplasty approach using autologous costal cartilage grafts, yielding a successful postoperative result.

Classification and treatment of the saddle nose deformity

The saddle nose deformity results from a disruption in the nose's integral support mechanisms. Reconstructive surgeons must not only reestablish facial aesthetic contours but also rebuild the nose's structural framework while preserving or restoring nasal function. The causes and the classification of saddle nose deformities are reviewed, and the preferred techniques of correction and reconstruction are illustrated.

Use of nasal septal bone to straighten deviated septal cartilage in correction of deviated nose

OBJECTIVES

Septoplasty for correction of deviated nose often requires removal of the deviated part of the quadrangular cartilage and the perpendicular plate of the ethmoid bone or vomer. In most cases, the removed bone is discarded. We describe our experience using septal bone for deviated nose correction, and analyze the postoperative results.

METHODS

A retrospective study was performed on 23 patients who underwent correction of deviated nose using nasal septal bone to straighten deviated septal cartilage from January 2004 to August 2008. The subjective satisfaction of patients was evaluated 6 to 12 months after rhinoplasty with a questionnaire. Aesthetic outcomes were evaluated by 2 independent rhinoplastic surgeons who compared preoperative and postoperative photographs. To evaluate outcomes objectively, we made anthropometric measurements of the deviated nose before and after surgery using facial photographs.

RESULTS

All patients indicated cosmetic satisfaction and improvement in nasal obstruction. The outcome analysis by 2 independent rhinoplastic surgeons indicated that 13 patients had excellent, 5 patients had good, and 5 had fair outcomes. Anthropometric measurements of the deviated nose showed that both the curved deviated angles and the linear deviated angle had improved (p < 0.05).

CONCLUSIONS

Use of nasal septal bone to straighten deviated septal cartilage appears to be feasible in corrective rhinoplasty, and may be particularly beneficial in cartilage-depleted patients.

Augmentation of the nasal dorsum with autogenous costal cartilage using the "edge-on" technique

Carved costal cartilage autografts are commonly used for nasal augmentation in saddle nose deformities. One major disadvantage of these carved grafts is postoperative warping. To prevent warping of costal cartilages, we used the "edge-on" technique. The inferior border of the cartilage is rotated 90 degrees to become the convex dorsum. No cartilage is trimmed or carved, and hence the intrinsic stress forces within the graft are not disturbed. The results in 21 patients are documented with long-term follow up (mean, 4 years) and showed no evidence of warping. Other complications, advantages, and disadvantages of the technique are discussed.

Dorsal nasal augmentation with rib cartilage graft: long-term results and patient satisfaction

Various alloplastic and autogenous materials have been used for dorsal nasal augmentation. Bone and cartilage autografts commonly are used. We used rib cartilage graft for dorsal nasal augmentation. The aim of this study was to investigate the long-term outcomes and patient satisfaction of dorsal nasal augmentation with rib cartilage grafts. Thirty-eight patients who had been operated on for dorsal nasal augmentation with rib cartilage graft were included in this study. Operation times, postoperative complications, and revision surgery were investigated by using hospital records. Anthropometric measurements were used for determining the resorption rate of cartilage graft. A questionnaire was used for the evaluation of long-term patient satisfaction. Evaluation of the patients' records showed that average operation time was 116 minutes and there were no complications such aspleural damage. The mean follow-up period was 27.4 months. Nine patients required secondary nasal surgery, including soft tissue augmentation (n = 1), nasal tip revision (n = 3), and reshaping the cartilage graft (n = 5). Long-term anthropometric measurements, comparing preoperative and postoperative values, documented increases in both tip projection (4.2%) and nasal length (1.2%) and an increase in nasolabial angle of 8.2 degrees . Eighty-one percent of the patients who answered the questionnaire rated the nasal size as normal. Nasal symmetry and nasal shape were good in 75% and 66% of the patients, respectively. Results of the rib cartilage grafts that are used for dorsal nasal augmentation are satisfactory for the patients and resorption rates are not high enough to change the shape of the nose.

Reconstruction of Saddle Nose Deformity With Three-Dimensional Costal Cartilage Graft

Saddle nose deformity is characterized by depression of the nasal bone and the cartilage dorsum associated with a collapse in the upper lateral and alar cartilages. Etiopathogenesis usually involves trauma or invasive excision of the bone and cartilage. Surgical treatment for functional and aesthetic recovery relies on the use of grafts. Options for grafting include autogenous tissue such as bone or cartilage and alloplastic augmentation. Nine patients with saddle nose deformity underwent surgical reconstruction with autogenous costal cartilage. The deformity was the result of trauma in seven patients and secondary to surgery in two patients. Cartilage obtained from the sixth and seventh ribs was used as the graft material to compensate for the low nasal dorsum. Cartilage was used as a single unit and shaped to cover the nasal dorsum and the lateral nasal walls completely. The upper lateral cartilages were fixed to shaped cartilage graft. Additional cartilage grafts into the columella and septum were also placed in all patients. Functional and aesthetic outcome was satisfactory in all patients. As a result, using costal cartilage graft, a single unit allowed more predictable and reliable reconstruction of the saddle nose deformity than the conventional dorsal grafts.

Fixation of the split calvarial graft in nasal reconstruction

Reconstruction of nasal contour where skeletal support is deficient or absent has usually been achieved using autogenous bone. Membranous bone taken from the cranium is clearly superior to rib or iliac crest when used as autografting material to the craniofacial skeleton. Conventionally, the bone graft is rigidly fixated to the recipient nasal bone with either metal plate-screw systems or Kirschner wires. Reported here are the results of a single biodegradable screw fixation of the split calvarial graft that is used for nasal reconstruction. Ten patients with moderate to severe saddle nose deformity underwent reconstruction using the open rhinoplasty approach. The graft was harvested from the outer cortex of the parietal bone, shaped, and secured in place with a single bioresorbable screw. No significant resorption has been observed in the grafts and a favorable aesthetic result was achieved in all of the cases. Described modification in fixation of the bone graft in nasal reconstruction avoids some of the disadvantages of permanent materials while preserving the advantages of rigid fixation.

Alveolar Ridge Augmentation: A Comparative Longitudinal Study Between Calvaria and Iliac Crest Bone Grafts

Insertion of endosseous implants is often difficult because of lack of supporting bone. In the case of severe atrophy of the jaws, a large volume of autogenous bone can be harvested from the iliac crest and calvaria. Both grafts undergo partial resorption with time, but the rate of bone loss has not been fully elucidated. The aim of this study was to evaluate the alveolar bone height gain (ABHG) obtained with iliac crest and calvaria bone grafts. Twenty-five patients had mandibular bone grafts, 32 had maxillary bone grafts, and 11 had both mandibular and maxillary bone grafts. Measures were made on preoperative, postoperative, and follow-up radiographs. A general linear model was used to evaluate the rate of ABHG plotted against months elapsed from the time of the operation to the time of follow-up. General linear model output showed a statistically significant effect for only the type of donor bone graft (P = .004), with a better ABHG for calvaria. The iliac crest bone grafts lost most of the ABHG in the first 6 months, whereas calvaria bone grafts lost ABHG over a greater interval of time. The type of bone graft is the strongest predictor of ABHG, and calvaria bone graft had a higher stability than did iliac bone graft. However, the gap in ABHG between the 2 grafts tended to decrease over time.

The use of lower turbinate bone grafts in the treatment of saddle nose deformities

Saddle nose reconstruction is based on the use of support grafts to manage aesthetic and functional problems. Bone (calvarial, iliac crest, costal, nasal hump, ulnar, and heterogeneous origin), cartilage (septal, costal, heterogeneous), and synthetic materials (silicon, silastic, polyethylene) were used as support grafts. Three patients have been included in this study to define the surgical management and long-term aesthetic and functional results of patients undergoing rhinoplasty with support grafts for a saddle nose deformity. Open rhinoplasty was employed. Both the lower turbinates were excised and the bone dissected from the soft tissues in two cases and in one case, only mucosa was removed. The amount of support needed was measured by using bone wax. The bone was used shaped in layers, according to the defect, and sutured to each other by vycril suture, and wrapped around by surgicell. The graft was then inserted in its place and fixed with external prolene sutures. Results were satisfactory in both function and aesthetics. Ten to 16-month follow-ups had no complications. Saddle nose surgery basically requires the use of a support graft to repair the nasal dorsum. A lower turbinate bone graft procedure has some advantages: it is cheap and safe, it is ready to use and not time-consuming, there is no donor area and no additional donor site morbidity, and it enlarges the airway and the passage to prevent nasal airway obstruction.