Reconstruction of the septum with an autogenous double-layered conchal L-strut

Functional evaluation of Septal L-strut extension graft in East Asians

BACKGROUND

The septal L-strut extension graft (SLEG) consists of anterior extended spreader graft and caudal septal extension graft. SLEG is used to increase the anterocaudal projection from a low-profile nose by creating the de-novo septum. This retrospective study verified the effectiveness of SLEG in improving the nasal function in East Asians.

MATERIALS

Medical records of patients who underwent septorhinoplasty with SLEG were retrospectively reviewed. The clinical features showed under-projected lower two-thirds of the nose with septal deviation, saddle nose, and short nose. We analyzed the post-operative changes in the NOSE score and variables of nasal geometry measured using acoustic rhinometry through long-term follow-up.

RESULTS

Patients were divided into two groups, those who underwent SLEG with turbinoplasty (Group A) and SLEG alone (group B). The NOSE scores decreased significantly in groups A and B, and the improvement was statistically more significant in Group A (p < 0.05). Acoustic rhinometry showed an increase in nasal cavity volume (VOL1) on the deviated side in Group A, and an increase in minimal cross-sectional area 1 (MCA1) on the deviated side in Group B (p < 0.05). The non-deviated side did not show significant reduction in MCA1 and VOL1 after SLEG with or without turbinoplasty. Thus, SLEG, by itself, improved airway function in East Asians.

CONCLUSIONS

SLEG has proven to be valuable in improving nasal function.

Snake-shaped ePTFE nasal tip graft combined with conchal cartilage in Asian rhinoplasty: a retrospective cohort study

BACKGROUND

Lacking a nasal tip projection is a common deformity of Asian nasals. Various commonly used nasal tip grafts require dissecting septal perichondrium, most of them are autologous cartilage with a nonintegrated design. A snake-shaped expanded polytetrafluoroethylene (ePTFE) nasal tip graft is an integrated, stable tip graft without any additional assembly and splicing, conforming to the nasal anatomy characteristics of Asians.

METHOD

A retrospective study was performed on Asian patients who underwent rhinoplasty in the nasal tip at Peking University Third Hospital from 2015 to 2022. Nasal tip grafts were categorized into three groups: snake-shaped ePTFE combined with conchal cartilage (n = 15), only costal cartilage (n = 25), and only conchal cartilage (n = 17). Patients were excluded if their rhinoplasty did not involve any of the grafts above. Visual Analogue Scale, FACE-Q Nose, FACE-Q Nostril, Nasal Obstruction Symptom Evaluation scale, and Rhinoplasty Outcome Evaluation scale were used to evaluate the preoperative and postoperative results.

RESULTS

Fifty-three (93.0%) cases had low nasal dorsum and 46 (80.7%) cases had short nose. There was no significant difference in complication rates among the three groups. The difference between preoperative and postoperative scale scores was statistically significant among the three groups (p < 0.05). Score improvements, including all scales, were the highest in the costal cartilage group and lowest in the conchal cartilage group.

CONCLUSIONS

Snake-shaped ePTFE nasal tip grafts can be an effective integrated alternative that provides long-term safety and efficacy compared with traditional autogenous implants (conchal and costal cartilages).

A Novel Ear Cartilage Caudal Septal Extension Graft

In cases of weak or deficient caudal septum, the caudal septum extension graft (CSEG) is the most commonly used reconstructive method. In the current study we introduce a newly-designed conchal cartilage CSEG and evaluate its cosmetic and functional outcomes. The graft has an average length of 3 ± 0.3 cm and composed of a distal double-layered part, which is 3 to 4 mm wide and a proximal single-layered part, which is 1.2 to 1.7 cm wide. The graft design allows the proximal single-layered part to be fixed on either sides of the caudal septum while keeping the distal double-layered segment in the midline. The study included 230 patients, of which 83% were revisions, all patients completed a validated patient-reported outcome measure (PROM) questionnaire pre- and postoperatively. The PROMs used were either the Nasal Obstruction Symptom Evaluation (NOSE) survey or the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS). During the mean follow-up period of 18.2 months (range: 9-192 months) no serious complications were encountered and only six cases (2.3%) required minor revisions of the CSEG.Using the proposed conchal cartilage, CSEG resulted in an improved cosmetic and functional outcome as evidenced by the significant postoperative improvement in the NOSE, SCHNOS-O, and SCHNOS-C scores with a p-value <0.001, <0.05, and <0.0001, respectively. The graft provided adequate tensile strength and support to the nasal tip, which resulted in improved tip projection, rotation, definition, and symmetry, while maintaining a degree of flexibility and elasticity which is much more than that of the rib or even the septum thus resulting in the most natural feel of the nasal tip lobule.

Folded Cymba Concha: Is It Large and Stable Enough for Caudal Septal Extension Graft in Asian Rhinoplasty?

BACKGROUND

Septal extension grafting (SEG) is used for nasal tip projection and positioning. Often, insufficient quadrangular cartilage is available for grafting in Asians, and in most secondary cases the septum is already harvested. We utilized the folded cymba concha as an alternative for caudal SEG (CSEG) by modifying a tongue-in-groove technique.

OBJECTIVES

The aim of this study was to evaluate the physical suitability of the cymba concha for CSEG and compare its outcomes with those of septal quadrangular cartilage.

METHODS

The mean length and width of 311 harvested consecutive folded cymba conchae were measured from intraoperative photographs. Data from 220 patients with >12 months of follow-up were retrospectively reviewed for clinical outcomes. Clinical demography was determined based on the need for additional spreader grafts. For clinical reliability, anthropometric photographs of patients in whom folded cymba conchae were used were compared with those in whom quadrangular cartilage was used.

RESULTS

Mean [standard deviation] lengths and widths of the folded cymba conchae in men and women were 24.2 [3.9] and 22.4 [3.7] mm, and 7.8 [1.9] and 7.2 [1.9] mm, respectively. Use of the folded cymba concha graft significantly increased nasal tip projection by 28.9% and columellar-labial angle by 9.7%, improving both aspects postoperatively. Anthropometric comparison revealed no significant differences between folded cymba conchae and septal cartilage in terms of nasal tip projection (P = 0.264) and postoperative columellar-labial angle (P = 0.182).

CONCLUSIONS

Folded cymba conchal cartilage can be a primary option for CSEG in Asian septorhinoplasty cases or for individuals with insufficient septal cartilage remnants.

40 Years of Total Extracorporeal Septal Reconstruction: The Past, Present, and Future

BACKGROUND

Even today, severe septal deformities are a challenging problem for any rhinoplasty surgeon. Standard techniques are often not able to achieve satisfactory long-term results regarding function or aesthetic form. In such severe cases, a partial or total extracorporeal septal reconstruction may be used, as these techniques provide reliable and lasting results.

METHODS

The aim of this work is to present the authors' experience with the technique of total extracorporeal septal reconstruction and its development to today's standard and to prove its effectiveness in the long-term follow-up.

RESULTS

This article presents 40 years of clinical experience in this field and describes the technical changes that have evolved. Low complication rates, safe techniques, and favorable long-term outcomes of the total extracorporeal septal reconstruction show the benefits of this technique.

CONCLUSION

The indication for a total extracorporeal septal reconstruction has been limited by the development of less complex surgical procedures, but it still represents the best technique to achieve long-term functional and aesthetic results in patients with very complex septal deformities.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Finesse in Caucasian Endonasal Rhinoplasty: The S.O.F.T. Concept

The nasal anatomy of Caucasian people includes thin skin, limited soft tissue volume, a high dorsum, strong cartilaginous framework, and narrow elliptical nasal inlets. A smooth dorsal contour, a well-defined tip, a naturally soft-feeling tip, and a functionally patent nasal valve constitute key objectives for Caucasian rhinoplasty. The author's focus on minimal-impact surgery has resulted in multiple novel techniques, embedded in a coherent algorithmic concept termed the S.O.F.T. (surgery and ongoing care free of trauma) concept. The foundation is the endonasal operation for the entire spectrum of primary and secondary deformities and maximal preservation of anatomic structures.

Septum-Based Nasal Tip Plasty: A Comparative Study between Septal Extension Graft and Double-Layered Conchal Cartilage Extension Graft

BACKGROUND

The septal extension graft is currently the most commonly used primary and secondary rhinoplasty technique in Asia because it provides maximal tip projection and rotational controllability. The authors compared the tip projection amount and rotational controllability of the tip support between the septal extension graft based on the L-strut septum and double-layer conchal cartilage graft based on the full septum at the nasal tip.

METHODS

Twenty-seven consecutive patients who underwent nasal tip plasty with the septal extension graft or double-layer conchal cartilage graft for purely aesthetic reasons between March of 2014 and July of 2016 were included. The nasal tip projection and columellar labial angle preoperatively (time 0), immediately postoperatively (time 1, an average of 2 weeks after the operation), and postoperatively (time 2, an average of 7 months after the operation) were analyzed with clinical photography.

RESULTS

Fourteen patients (group A) underwent septal extension graft surgery and 13 (group B) underwent double-layer conchal cartilage graft surgery. Changes of 61 and 74 percent in tip projection ratio were immediately achieved and were maintained after surgery for groups A and B, respectively (time 2 versus time 0 dividing time 1 versus time 0; p = 0.722 for groups A and B). Therefore, the relapse ratio of this technique was 39 and 26 percent for groups A and B, respectively.

CONCLUSIONS

This comparative study between the septal extension graft and double-layer conchal cartilage graft showed that both nasal tip plasties are similar in terms of stability. Considering the fact that the double-layer conchal cartilage graft could preserve septal support, this technique could become an effective and safe alternative option for rhinoplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

3D Photogrammetric Analysis of the Nasal Tip Projection and Derotation Based on the Nasal Tip Quadripod Concept

BACKGROUND

Regarding septal fixation in nasal tip plasty, the nasal tip tripod theory may require modification. We performed three-dimensional (3D) photogrammetric analysis of the "Skiff graft," which is a quadripod method involving folded conchal cartilages fixated on the caudal septal angle, paired lateral crura reinforced by a derotational conchal cartilage graft, and conjoined medial crus on the columella base. We assessed the efficacy of the Skiff graft in maintaining tip projection and preventing cephalic rotation of the nasal tip.

METHODS

In total, 39 patients who underwent nasal tip plasty with the Skiff graft during 2012-2015 and underwent 3D photogrammetry before (T0), immediately postoperatively (T1, average of 1 week postoperatively), and an average of 215 days postoperatively (T2) were included. Nasal tip projection was objectively measured from images using a software program.

RESULTS

The average differences between the T0 and T1, T0 and T2, and T1 and T2 lengths were 4.81, 3.57, and 0.85 mm, respectively. Thus, 81% of the change in tip projection length that had been achieved immediately postoperatively was maintained at T2 based on 3D photogrammetry (P < 0.001). The relapse ratio of the examined technique was 19.26% (mean, 0.85 mm; P < 0.001).

CONCLUSIONS

Nasal tip plasty with the Skiff graft preserves septal support and is an effective primary and revision rhinoplasty technique in Asian patients. This approach may be suitable as an alternative to nasal tip plasty with the septal extension graft in terms of maintaining nasal tip projection, rotational controllability, and nasal mobility.

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 .

Comparison of Clinical Results in Nasal Tip Augmentation Either Via Face to Face or Back to Back Technique With Autogenous Auricular Conchal Cartilage

OBJECTIVE

To compare the objective and subjective findings between patients who underwent nasal tip augmentation surgery via two different methods using autogenous auricular conchal cartilage.

MATERIALS AND METHODS

This study included the data of 21 patients who underwent nasal tip augmentation surgery. The patients were randomly divided in two groups according to the technique used to form a double layer columellar strut graft; either face to face (group 1) and back to back (group 2). All patients were assessed via nasal obstruction symptom evaluation scale (NOSE) and via acoustic rhinometry and rhinomanometry at preoperative and postoperative 1st and 6th months.

RESULTS

There was statistically significant improvement in symptom score in both patient groups with no difference inbetween. Total nasal resistance decreased nonsignificantly at the end of 6th month in both groups; 13.1 Pa/cm3 to 8.6 Pa/cm3 and 10.3 Pa/cm3 to 9.5 Pa/cm3 respectively. There was no significant increment in MCA values for both groups except left MCA1.

CONCLUSIONS

We achieved good results in tip augmentation via both techniques. An autogenous conchal cartilage is a good alternative to replace lacking caudal septal cartilage. It provides safe and stable support to the nasal tip. However, further comprehensive studies with larger sample size and long follow-up are required to elucidate any difference between these two techniques.