Spreader flaps for middle vault contour and stabilization

Is There a Risk of Saddle Nose Deformity after Spreader Grafts and Flaps?

Spreader grafts have been used successfully for years to augment the nasal valves among other indications. Spreader flaps have been described as an alternative. However, the literature discussing the complications of these procedures is scarce. This study aims to report and discuss the improvements and complications resulting from using spreader grafts or flaps in a cohort of patients operated upon by the author. Particular stress is given to a group of patients who developed saddle nose deformity after surgery. This cohort included 80 cases of rhinoplasty involving the use of spreader grafts or/and flaps. There was a highly significant improvement in nasal functions postoperatively. Postoperative saddle nose deformity was observed in five patients (6.25%). Spreader grafts/flaps are highly effective in improving nasal functions, but saddle nose deformity appears to be a possible risk. This complication has not been previously reported in the literature in relation to these procedures.

Functional Nasal Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) understand the functional significance of nasal anatomy as it relates to rhinoplasty and perform a comprehensive functional nasal assessment. (2) Identify the anatomical level of obstruction based on the authors' algorithmic approach and understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, external nasal valve collapse. (3) Understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, and external nasal valve collapse. (4) Appreciate the objective assessment tools for functional nasal surgery from a clinical and research perspective.

SUMMARY

The intent of functional rhinoplasty is to improve nasal airflow (and the perception thereof) by surgically correcting the anatomical sources of obstruction in the nasal airway. Cosmetic and functional rhinoplasty are not mutually exclusive entities, and the techniques that address one area, inevitably may affect the another. The rate of functional problems after cosmetic rhinoplasty range from 15 to 68 percent with nasal airway obstruction found to be the most common indication for secondary surgery. The objective of this CME article is to provide readers with an understanding of the (1) functional components of nasal anatomy, (2) clinical functional assessment, and (3) the current evidence supporting corrective maneuvers for each component.

Role of spreader flaps in primary rhinoplasty, functional and aesthetic outcomes: a systematic review

BACKGROUND

The standard treatment for reconstructing the middle vault of the nose is to use spreader grafts. Recently, an alternative technique using spreader flaps has become widely accepted.

METHODOLOGY

A literature search was performed in ΜEDLINE, Science Direct, the Cochrane Library and multiple trial registries. The systematic review included studies evaluating the effectiveness of spreader flaps, with or without comparison to the spreader graft technique, in patients who had undergone primary rhinoplasty.

RESULTS

Thirteen studies with a total of 500 patients met the inclusion criteria and were reviewed systematically. All studies measured breathing function improvement. Additionally, aesthetic improvement/satisfaction was evaluated in seven studies. The use of spreader flaps seems to improve breathing function, as seen in twelve out of thirteen studies. Furthermore, the studies assessing the aesthetic aspect of a primary rhinoplasty showed that spreader flaps can provide satisfactory results. The comparison between spreader flaps and spreader grafts showed similar results in most studies dealing with this topic in both the breathing function improvement and aesthetic improvement/satisfaction domains.

CONCLUSIONS

This study is the first systematic review assessing the functional and aesthetic outcomes of spreader flaps in primary rhinoplasty, and it shows encouraging results comparable to those of spreader grafts.

An Alternative Method for Midvault Restoration: "T-Splay Graft"

BACKGROUND

The internal nasal valve is one of the highly important anatomical points in rhinoplasty procedures. As a key anatomical area, the anatomical and functional integrity of this region must be preserved or reconstructed during rhinoplasty procedures. Several techniques have been defined in the literature for midvault restoration, among which, the most common are spreader grafts and flaps. Both techniques achieve a natural and harmonic contour but may fail to provide the splay effect to the upper lateral cartilages in some cases. A new technique known as the "T-splay graft", to be used as an alternative approach in cases where there is a risk of midvault collapse, and in which the splay effect in the upper lateral cartilage is preferred to be augmented, is explained in the present study.

METHODS

In the present study, a septal tunnel is opened of sufficient size for the cartilage graft planned for placement, at the planned level of the septum, to expand the midvault region and create a splay effect. A bilateral pocket is created in the inferior mucosa of the upper lateral cartilages. The harvested cartilage graft is passed through the septum in the horizontal plane. The cartilage graft is inserted into the bilateral pockets so as way to create convexity to the dorsum.

RESULTS

As a result of the applied method, it was established that the internal nasal valve angle could be expanded to the desired extent and the dorsal aesthetic lines could be achieved in a normal anatomical structure.

CONCLUSIONS

This technique enables the lateral direction of the tension between the graft and the upper lateral cartilages, and the creation of a splay effect. As such, we believe that this method is a highly effective alternative for use in appropriate cases.

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 .

Piezo-Assisted Dorsal Preservation in Rhinoplasty: When and Why

BACKGROUND

Preservation rhinoplasty philosophy with its "down techniques" is currently undergoing a renaissance. Its goal is to spare and preserve noble nasal structures such as ligaments, nerves and vessels, reducing to a minimum local tissue manipulation and avoiding the drawbacks and pitfalls associated with classic dorsal reconstruction techniques often resulting in irregularities which often lead to an increased rhinoplasty revision rate.

METHODS

In this article, we reviewed 107 consecutive cases in which a variety of preservation techniques were used. Indications, surgical techniques and complications are also described.

RESULTS

All reported procedures showed low complication rates with good cosmetic and functional outcomes.

CONCLUSIONS

Tailoring the surgical technique is essential in rhinoplasty. Authors have developed and present an anatomy-based diagram to help surgeons in choosing the right approach for dorsal surgery.

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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluation of the Effect of Conventional Rhinoplasty with Autospreader Flap and Let-Down Technique on Nasal Functions

Let-down technique, in which high septal strip resection is performed, and conventional rhinoplasty using autospreader flaps were compared regarding nasal functions with Nasal Obstruction Symptom Evaluation (NOSE) and Sinonasal Outcome Test-22 (SNOT-22) quality-of-life scale questionnaires. A total of 54 patients who were included in the study were divided into two groups: group 1 (autospreader group; n = 27) and group 2 (let-down group; n = 27). Open technical septorhinoplasty operation using an autospreader flap was performed in group 1. Let-down rhinoplasty was applied in group 2. NOSE and SNOT-22 scales were filled for the groups in the preoperative and postoperative periods and were compared. Postoperative values were found to be significantly lower than preoperative values in both groups (p < 0.001). When the groups were compared in between, no significant difference was seen according to the scales (p > 0.05). There was also no significant difference between the groups regarding age and gender. Although there was no significant difference between the two techniques, both NOSE and SNOT-22 quality-of-life scales have shown improvement both in conventional rhinoplasty with autospreader flap and let-down technique.

History of Dorsal Preservation Surgery: Seeking Our Historical Godfather(s) for the "Push Down" and "Let Down" Operations

There are 2 approaches for lowering the osseocartilaginous nasal dorsum. The most frequently used method includes resection of the osseocartilaginous nasal dorsum. The second method is based on preservation of the osseocartilaginous nasal dorsum. The concept of dorsal preservation surgery is to preserve, not resect, the nasal bones and upper lateral cartilage. Reduction rhinoplasty with preservation of the nasal dorsum is not only possible, but results in a natural appearing postoperative dorsal esthetic line. Thus, the rhetorical question: Why reconstruct the nasal dorsum when you can simply preserve it?

Double Columellar Strut: A New Method for Tip Surgery-A Study of 642 Cases with a 15-Year Follow-up

GOAL

Of the first nasal tip modeling procedures performed, the Anderson tripod concept is the most well known, and many anatomy-related studies have analyzed the components involved in tip surgery. The main goals of nasal tip surgery are to stabilize the tip complex, which largely affects the shape, projection and rotation of the nasal tip.

OBJECTIVE

The present study describes a new, original method, the double columellar strut and its main advantages compared to conventional techniques used for structural rhinoplasty.

METHODS

The study involved 642 patients (496 women and 146 men, with an average age of 38.67 years) who underwent surgery between 2004 and 2018 by two operators. The patients were re-examined to evaluate the outcomes at least 1 year after surgery, and long-term results (15 years) were recorded for the oldest patients in regard to esthetics (projection, shape, rotation) and breathing function.

RESULTS

Of the 642 patients, 34 required a surgical revision for minor defects of the tip due to asymmetry, and the natural appearance after the first surgery was not affected. For the primary rhinoplasties, there were no breathing disorders that required revision surgery due to systematic restoration or preservation of the middle third.

CONCLUSION

The double columellar strut could be performed in the same conditions that the others conventional structural grafts. As a polyvalent alternative, it can be used with closed or open approaches and involves the use of only a limited amount of cartilaginous material. This anatomical approach yields natural results, acting as a foundation for controlling the shape, projection and rotation of the nasal tip. In addition, with or without complementary techniques such as the "tongue-in-groove" technique or tip grafts, the double columellar strut can be considered a "multifunction pocket knife" for tip surgery.

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 .

The Combined Use of Spreader Flap and Asymmetric Spreader Graft in Crooked Nose

OBJECTIVE

The crooked nose is still a challenging deformity for rhinoplasty surgeons although a significant number of correction methods have previously been described. The aim of this study is to present a new technique that the authors have used to correct the crooked nose in selected patients.

MATERIALS AND METHODS

This retrospective study was carried out on 53 patients who underwent open technique rhinoplasty due to crooked nose. Pictures were taken from five different angles using digital cameras and recorded pre- and postoperatively. Patients who have a minimum follow-up period of 12 months are included in the study.

RESULTS

Fifty-three patients who have I-shaped and C-shaped crooked nose were enrolled in this study. The mean ages were 27.4 years. The mean follow-up period of the patients was 19.1 months. Patients who have I-shaped and C-shaped crooked nose deviation angle values were calculated preoperatively as 7.1 ± 2.1 and 163.4 ± 3.6, respectively. Postoperatively, deviation angle values were 0.75 ± 0.83 and 177.9 ± 3.1. Postoperative deviation angles were significantly lower than preoperative angles on patients who have I-shaped crooked noses (p < 0.001). On patients who have C-shaped crooked nose, postoperative deviation angles were significantly higher than preoperative angles (p < 0.001).

CONCLUSIONS

This unique study shows that the combined use of one-sided spreader flap and asymmetric spreader grafts is a very good choice for satisfactory long-term outcome and durable correction of crooked nose deformity.

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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

A Novel Hump Reinsertion Technique to Reconstruct the Nasal Dorsum

Nasal hump removal and modification is a commonly performed procedure in rhinoplasty. The spreader flap is most commonly used in the reconstruction technique and involves suturing the medial end of the upper lateral cartilage (ULC) onto the septum. In this study, author presents a new hump removal technique that includes a novel procedure for hump reinsertion and suturing that is easy and comfortable to apply in hump removal operations. The records of the patients were assessed retrospectively from private practice. Patients who had undergone hump removal operations using a hump reinsertion graft were included. In total, 54 patients met the inclusion and exclusion criteria, and their records were assessed. The hump was divided into 3 parts longitudinally. The septum, which is a part of the nasal hump, was prepared as a strut graft, and the ULCs were prepared as spreader grafts. A novel suturing technique was used while the spreader grafts were fixed. This technique was used if the ULC was larger than 3 mm. The patients were evaluated using the "Rhinoplasty Outcome Evaluation" (ROE) 12 months after surgery. The initial median ROE score was 40.5; after surgery, it increased to 88.5. The ROE score changed significantly (P < .001). The postoperative results were satisfactory. After assessments, no asymmetry or functional problems were found in all participants. This technique allows for closed rhinoplasty without the need for an additional graft from the septum, enhancing the prevention of displacement and improving functionality.

Decision-Making in Middle Vault Reconstruction following Dorsal Hump Reduction in Primary Rhinoplasty

BACKGROUND

Dorsal hump reduction during open rhinoplasty disrupts the continuity between the upper lateral cartilages and the dorsal septum. Options to reconstitute the midvault include primary closure of the upper lateral cartilages to the dorsal aspect of the septum, placement of spreader grafts, and creation of spreader flaps. The authors sought to clarify from highly experienced rhinoplasty surgeons their decision-making rationale for midvault reconstruction, distilling down the group consensus into algorithmic guidelines.

METHODS

A panel of internationally recognized rhinoplasty surgeons participated in a two-part organized communication method. An introductory summit consisted of open discussions on various topics in midvault reconstruction. The summit transcription was analyzed by thematic content analysis to develop a survey encompassing clinical scenarios for primary rhinoplasty, which was then individually administered to each panelist. Data gathered from both parts were used to generate technical guidelines and a decision-making algorithm.

RESULTS

The panelists identified the following anatomical features as pertinent to their selection of midvault reconstruction method: size of the dorsal hump reduction, width of the midvault relative to the upper vault, presence of dorsal angulation, and presence of nasal obstructive symptoms. Individual panelist preference was gathered from the 24-scenario survey divided into either cosmetic or functional rhinoplasty cases.

CONCLUSIONS

Management of the midvault after dorsal hump reduction is important to establish proper aesthetic relationships and to provide functional integrity of the internal valve. Our authors present an algorithmic approach to decision-making based on the systematic analysis practiced by senior rhinoplasty surgeons.

The Probable Reasons for Dorsal Hump Problems following Let-Down/Push-Down Rhinoplasty and Solution Proposals

BACKGROUND

Nasal hump relapse and its probable reasons or mechanisms have been less discussed after dorsal preservation rhinoplasty. In this article, the authors would like to share their experiences and offer solutions regarding this subject.

METHODS

Five hundred twenty patients who underwent primary rhinoplasty between the years 2016 and 2018 were included in the study. The push-down method was used for noses with a hump less than 4 mm and the let-down procedure was performed for others. Hump height was measured from profile photographs. The cases were evaluated in terms of nasal dorsal problems and their probable mechanisms.

RESULTS

Five hundred twenty patients, 448 with a straight nose and 72 with a deviated nose, were enrolled in this study. Mean follow-up was 13 months (range, 9 to 16 months). Visible dorsal hump recurrence was observed in 63 patients, and they appeared at 1 to 4 months postoperatively. Forty-one of these had a dorsal hump more than 4 mm preoperatively. Hump recurrence was not more than 2 mm in 34 patients, and they did not wish to have any revision intervention because of cosmetic satisfaction. In 11 cases, the height of the hump recurrence was 2 to 3 mm. These patients were treated with only minimal rasping. The remaining 18 patients had a hump recurrence with a height of 3 to 4 mm. They underwent secondary surgery using let-down rhinoplasty.

CONCLUSION

The authors recommend subperichondrial/subperiosteal dissection, subdorsal excision of cartilaginous and bony septum, scoring the resting upper part of the septum just below the keystone area, and performing lateral keystone dissection and preferring let-down procedure for kyphotic noses to prevent hump relapse after dorsal preservation rhinoplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Thermo-Mechanical Behaviour of Human Nasal Cartilage

The aim of this study was to undergo a comprehensive analysis of the thermo-mechanical properties of nasal cartilages for the future design of a composite polymeric material to be used in human nose reconstruction surgery. A thermal and dynamic mechanical analysis (DMA) in tension and compression modes within the ranges 1 to 20 Hz and 30 °C to 250 °C was performed on human nasal cartilage. Differential scanning calorimetry (DSC), as well as characterization of the nasal septum (NS), upper lateral cartilages (ULC), and lower lateral cartilages (LLC) reveals the different nature of the binding water inside the studied specimens. Three peaks at 60–80 °C, 100–130 °C, and 200 °C were attributed to melting of the crystalline region of collagen matrix, water evaporation, and the strongly bound non-interstitial water in the cartilage and composite specimens, respectively. Thermogravimetric analysis (TGA) showed that the degradation of cartilage, composite, and subcutaneous tissue of the NS, ULC, and LLC take place in three thermal events (~37 °C, ~189 °C, and ~290 °C) showing that cartilage releases more water and more rapidly than the subcutaneous tissue. The water content of nasal cartilage was estimated to be 42 wt %. The results of the DMA analyses demonstrated that tensile mode is ruled by flow-independent behaviour produced by the time-dependent deformability of the solid cartilage matrix that is strongly frequency-dependent, showing an unstable crystalline region between 80–180 °C, an amorphous region at around 120 °C, and a clear glass transition point at 200 °C (780 kJ/mol). Instead, the unconfined compressive mode is clearly ruled by a flow-dependent process caused by the frictional force of the interstitial fluid that flows within the cartilage matrix resulting in higher stiffness (from 12 MPa at 1 Hz to 16 MPa at 20 Hz in storage modulus). The outcomes of this study will support the development of an artificial material to mimic the thermo-mechanical behaviour of the natural cartilage of the human nose.

Role of Spreader Flaps in Rhinoplasty: Analysis of Patients Undergoing Correction for Severe Septal Deviation with Long-Term Follow-Up

INTRODUCTION

The aim of this randomized controlled study was to analyze the long-term results of patients undergoing rhinoplasty because of severe septal deviation and to evaluate the stability of results.

MATERIALS AND METHODS

The study was performed with a randomized design. Patients were randomly divided into four groups: group 1, spreader flaps were used in combination with spreader grafts; group 2, spreader flaps were used alone; group 3, spreader grafts were used alone; and group 4, neither spreader flaps nor grafts flaps were used. Patients answered the Italian version of the FACE-Q rhinoplasty module. Anthropometric measurements were performed by AutoCAD for MAC. We determined the angle of deviation, and we compared the pre- and postoperative angles and compared patient satisfaction in the four groups using the Chi-squared test for unpaired data. Two plastic surgeons reviewed all the postoperative photographs of the study patients and rated the photographs on a scale of 1 to 5.

RESULTS

A total of 264 patients who underwent primary rhinoplasty between January 2010 and September 2016 satisfied the inclusion criteria and were finally enrolled in this study. Anthropometric measurements revealed statistically significant differences (P < 0.01) between the preoperative and postoperative values for the angle of septal deviation in group 1 versus the other groups. Over the long-term follow-up, group 1 maintained an angle close to 180 degrees (P < 0.01). Group 1 and group 3 were more satisfied compared with groups 2 and 4 (P < 0.01). According to evaluations by the 2 reviewers, group 1 and group 3 were the most satisfactory outcomes (P < 0.01).

CONCLUSIONS

This was the first randomized study to show that the combined use of the spreader flap and spreader graft is the best choice for a good long-term outcome and durable correction of septal deviation.

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 .

Outcome of rhinoplasty in patients undergoing autospreader flaps without notable dorsal hump reduction: A clinical trial

BACKGROUND

Reconstruction of the nasal midvault is an important component of successful rhinoplasty outcomes. Use of the autospreader flap is a beneficial technique for preserving the middle vault. In the present study, we evaluated the esthetic and functional outcomes of this technique in patients without notable dorsal hump reduction.

METHODOLOGY

A nonrandomized clinical trial was performed from December 2017 to April 2018 with a minimum follow-up time of 6 months. From among patients seeking rhinoplasty, 38 were eligible for inclusion in the study. The autospreader flap was used to recreate the middle vault in patients undergoing open rhinoplasty, with up to 2 mm bony and cartilaginous dorsal hump removal. Preoperative and postoperative standard photographs were obtained. Assessment of patients was based on Rhinoplasty Outcome Evaluation (ROE) and Nasal Obstruction Symptom Evaluation Scale (NOSE) scores. Objective assessment included quantitative analysis of anthropometric angles, mean dorsal width, nasal length, and projection which was performed on standard pre- and postoperative photos.

RESULTS

Overall, the patients had statistically significant improvement in their postoperative NOSE scores (9 vs. 6.92, p = 0.0001). The majority of patients were satisfied with the postoperative appearance of their noses. The mean nasal dorsal width (NDW) decreased postoperatively (43% vs. 36%). No difference was found between the mean height of the nose and projection pre- and postoperatively. There was a significant postoperative increase in the nasolabial angle and reduction in nasal length.

CONCLUSIONS

The autospreader flap is an effective technique for preservation and restoration of the middle vault and dorsal esthetic line in cases of less than 2 mm dorsal hump reduction. Nasal function can be improved while achieving good cosmetic outcomes.

Rhinoplasty: lessons from "errors" : From anatomy and experience to the concept of sequential primary rhinoplasty

BACKGROUND

Reshaping the nose can be achieved following 3 main concepts: preservation and reshaping of normal anatomy, resection of nasal deformities, reconstruction of nasal framework. Time, experience and nasal anatomic knowledge are keys to understand nasal biomechanics.

OBJECTIVES

To describe how experience and morphodynamic anatomy lead to a new concept of sequential primary rhinoplasty, resulting in reducing revision rhinoplasties.

METHODS

Through 36 years' experience in different rhinoplasty procedures, 25 years in personal anatomic studies of the nose and reviewing the last 15 years including 600 patients who underwent new concepts in primary rhinoplasty out of 1200 patients operated during this period, the author analyzes how nasal anatomic layers, surgical approaches, and morphological effect of the time interact to modify the aesthetic results according to current rhinoplasty concepts.

RESULTS

Nasal bony cartilaginous vaults biomechanics understanding leads to consider the K‑area as a flexible joint which can be reshaped without resection of the nasal vaults. The role of the subdorsal septum is highlighted as the main anatomic structure which can be safely resected in rhinoplasty, and which allows to respect the natural anatomy, the nasal valves and the dorsal aesthetic lines. Description of nasal compartments divided by the "T" ligament leads to rethink the incisions and approaches of the nose: the interseptal-columellar and extended infracartilaginous incisions allow to protect nasal ligaments and to perform a deep plane undermining. Protection of the anatomic layers allows quick recovery, nasal function improvement and long-lasting results.

CONCLUSION

The goal to reduce the rate of revision rhinoplasty and to improve the natural results can be achieved, considering the concept of sequential primary rhinoplasty. Nasal soft tissues are protected as far as possible. The current rhinoplasty concepts are not antagonist but appear as an intraoperative succession of alternative techniques from anatomy and function preservation to reconstruction of the nasal framework.

Effect of Spreader Graft on Nasal Functions in Septorhinoplasty Surgery

OBJECTIVE

The authors aimed to investigate the effect of spreader grafts on nasal function in septorhinoplasty (SRP).

METHODS

A prospective randomized double-blind study was conducted. Thirty patients who underwent SRP operation between October 2011 and January 2013 were divided into 2 equal groups randomly. Fifteen patients underwent SRP surgery without spreader graft technique (Group I) and 15 patients underwent SRP surgery with spreader grafts (Group II). Preoperative and postoperative evaluation included visual analog score (VAS) and acoustic rhinometry test.

RESULTS

Visual analog scores and acoustic rhinometry measurements of Group I and Group II patients were compared. Statistically significant difference was found for VAS scores of both the sides of the nasal cavity (both before and after topical decongestion) (P < 0.05), except for the VAS on the right side of the nasal cavity before decongestion (P > 0.05). On acoustic rhinometry test the difference was statistically significant for minimal cross-sectional area (MCA) and volumetric values (VOL)-MCA1, MCA2, VOL1, VOL2 values on the left side of the nasal cavity (both before and after topical decongestion) (P < 0.05) but not on the right side of the nasal cavity (P > 0.05).

CONCLUSIONS

Performing spreader graft technique in SRP surgery can prevent the narrowing of the internal nasal valve area after surgery and maintain adequate airway for respiration.

Dorsal Preservation: The Push Down Technique Reassessed

Management of the nasal dorsum remains a challenge in rhinoplasty surgery. Currently, the majority of reduction rhinoplasties results in destruction of the keystone area (K-area), which requires reconstruction with either spreader grafts or spreader flaps, both for aesthetic and functional reasons. This article will present the senior author's current operative technique for dorsal preservation in reduction rhinoplasty based on 320 clinical cases performed over a 5-year period. The author's operative technique is as follows: (1) endonasal approach; (2) removal of a septal strip in the subdorsal area whose shape and height were determined preoperatively; (3) complete lateral, transverse, and radix osteotomies; and (4) dorsal reduction utilizing either a push down operation (PDO) or a let down operation (LDO). The PDO consists of downward impaction of the fully mobilized nasal pyramid and is utilized in patients with smaller humps (Less than 4 mm). The LDO consists of a maxillary wedge resection and is performed in patients who need more than 4 mm of lowering. A total of 320 patients had a dorsal preservation operation (DPO). Postoperatively, there were no dorsal irregularities nor inverted-V deformities. Among our 44 personal revision cases, 27 patients (8.74%) had had a previous DPO, 16 of whom required tip revisions with no further dorsal surgery. Of the remaining 11 patients, the main problems were either hump recurrence and/or lateral deviation of the dorsum or widening of the middle third, which required simple surgical revision. Based on the authors' experience, adoption of a PDO/LDO is justified in selected primary patients. The key question before any primary rhinoplasty procedure should be "Can I keep the nasal dorsum intact?" Precise analysis and surgical execution are required to preserve the dorsal osseocartilaginous vault and K-area. Dorsal preservation results in more natural postoperative dorsum lines and a "not operated" aspect without the need for midvault reconstruction. Moreover, this technique is quick and easy to perform by any rhinoplasty surgeon. Rhinoplasty surgeons should consider incorporating dorsal preservation techniques in their surgical armamentarium rather than relying solely on the Joseph reduction method or an open structure rhinoplasty.

Update in the management of the middle vault in rhinoplasty

PURPOSE OF REVIEW

The middle vault of the nose continues to be a topic of interest among surgeons interested in aesthetic and functional rhinoplasty. The purpose of this review is to present currently accepted concepts regarding the significance of the middle vault of the nose in rhinoplasty and to review the more frequently advocated methods to be used in the correction of deficiencies.

RECENT FINDINGS

Spreader grafts may be at least as effective as flaring sutures in improving the airway. Studies have shown an improvement in quality of life and nasal breathing with the use of autospreader flaps. The correlation between acoustic rhinometry and clinical symptoms of nasal obstruction, however, has fallen short of providing clear diagnostic value.

SUMMARY

The diagnosis of middle vault collapse and nasal valve obstruction remains largely clinical. The patient's reported symptoms of nasal obstruction are diagnostically considered along with the findings of clinical examination, including the findings of a modified Cottle maneuver.The use of spreader grafts and autospreader flaps has been popularized to correct problems in the middle vault of the nose and will be presented in detail in this manuscript.

Evaluation of postoperative patient satisfaction after covering the nasal dorsum with upper lateral cartilage: "upper lateral closing"

Introduction

Following nasal hump removal during septorhinoplasty, the middle vault should be reconstructed to avoid functional and esthetic problems. Middle vault reconstruction, however, may result in widening of the middle vault and may need a camouflage graft to cover dorsal irregularities.

Objective

To present the results of reconstructing the middle vault with a technique that covers the nasal dorsum with upper lateral cartilage, from the viewpoint of patient satisfaction.

Methods

Retrospective study of patients who underwent septorhinoplasty that included nasal dorsum closure with upper lateral cartilage from December 1, 2014 to January 31, 2016. Those with postoperative follow-up of less than 3 months were excluded. The final study group included 39 patients. The same surgeon performed all septorhinoplasties. The dorsum was closed using an “upper lateral closing” technique that approximated upper lateral cartilages to each other over the septum. Postoperative patient satisfaction was determined using a visual analog scale and the rhinoplasty outcomes evaluation questionnaire. The questionnaire evaluates patient esthetic and functional satisfaction with the operated nose. High scores indicate improved esthetic results.

Results

No dorsal irregularities were seen at postoperative follow-up evaluation of the patients. For esthetic nasal appearance, the median visual analogue scale scores was 86%, and the mean for the questionnaire was 77.03%.

Conclusion

The natural dome-shaped anatomy of the nasal dorsum was achieved by approximating the upper lateral cartilages to each other. Closing the dorsum with this technique also covers any dorsal irregularities and results in a smooth dorsum. Patients expressed satisfaction with the esthetic and functional aspects of the smooth, attractive nasal dorsum.

Technical and Clinical Considerations for Facial Feminization Surgery With Rhinoplasty and Related Procedures

Importance

Together with the forehead reconstruction, feminization of the nose is one of the most common procedures in facial feminization surgery. Rhinoplasty surgical techniques, which provide correct support and stability in the midterm to long term, are essential for obtaining a predictable result.

Objective

To report on the technical and clinical considerations of rhinoplasty and related procedures to feminize the nose, harmonize the nose in relation to the other modified structures (mainly the forehead and maxillomandibular complex), and achieve an aesthetic result beyond gender differences.

Design, Setting, and Participants

Case series study of feminization rhinoplasties, in combination with lip-lift techniques, forehead reconstruction, and other procedures, were performed at a private practice between January 11, 2010, and May 29, 2015, in 200 consecutive male-to-female transgender patients. The mean (SD) medical follow-up for patients was 32 (18.84) months (range, 12-77 months). Frontonasal angles were objectively measured. Postoperative and long-term patient satisfaction were assessed.

Main Outcomes and Measures

Clinical analysis and evaluation using the 5-point Nose Feminization Scale, with 1 indicating very masculine or nose is worse and 5 indicating very feminine or exceptional result.

Results

In these 200 patients, the mean (SD) age was 40.2 (12.2) years (range, 18-70 years). The mean (SE) frontonasal angle changed from 133.64° (0.63°) to 149.08° (0.57°) (difference in means, -15.44; 95% CI, -17.12 to -13.76; P < .001). Most patients considered their nose to appear more feminine after the surgery, and the degree of satisfaction after the rhinoplasty was 4 (much better) of 5 points on the Nose Feminization Scale. During the evaluation of feminization rhinoplasties, special attention was given to how the nose relates to other features essential to the identification of facial gender: the forehead and maxillomandibular complex. Emphasis was placed on the midterm to long-term stability of the results by reinforcing the internal structure.

Conclusions and Relevance

In this case series of feminization rhinoplasties in combination with lip-lift techniques and forehead reconstruction, frontonasal angles were changed, and patient satisfaction with outcomes was high. The main goal of rhinoplasty in facial feminization surgery is to obtain feminine nasal features and the harmonization of the nose with the rest of the face. Lip-lifts and frontonasal recontouring can complement rhinoplasties associated with facial feminization surgery.

Level of Evidence

4.

Early Results and Description of a New Modification of Spreader Graft to Enlarge Nasal Valve Area: Modified Triangular Spreader Graft

OBJECTIVE

Nasal valve area is an important, functional part of nose and there are several different methods that have been used to enlarge that area for a better breathing function. In this study, the authors aimed to study the efficacy of a new spreader graft modification that was crafted in a triangular shape to enlarge nasal valve area.

METHODS

Twenty-two patients who underwent rhinoplasty operation with this new technique composed the study group. Average age of patients was 21.4 ± 2.1, 13 of them were men (59%) and 9 of them were women (41%). Same surgeon operated all 22 patients with the same technique that included usage of modified triangular spreader graft. Surgical outcomes were assessed by visual analog scale and nasal obstruction symptom evaluation scale preoperatively and 3 months postoperatively.

RESULTS

None of the patients had complications or aesthetic deformities according to surgeon after surgery. Average of nasal obstruction symptom evaluation scale score was 64.3 before surgery which reduced to 17.9 at postoperative third month. Also average visual analog scale score was 2.6 before surgery and it was 8.1 3 months after surgery indicating a better breathing sensation (P < 0.001).

CONCLUSIONS

Modified triangular spreader graft usage is a safe and effective method to enlarge nasal valve area with satisfactory aesthetic outcomes and good functional results because of its compatibility with anatomic position of nasal valve area.

Reinserting the Hump in Primary Rhinoplasty: The Gain Is Three-fold

BACKGROUND

Hump reduction in aesthetic rhinoplasty destabilizes the middle vault. Secondary maneuvers are necessary to avoid the long-term functional and aesthetic sequelae of middle vault collapse. We describe a new technique of reinserting the resected hump that combines (a) placement of the modified hump between the upper laterals and (b) bridging sutures between the upper laterals.

METHODS

Retrospective review of patients undergoing primary aesthetic rhinoplasty with hump resection.

RESULTS

Sixty-two patients, 46 with a straight and 16 with a deviated nose, enrolled. Twenty-three patients were operated through an open approach and 39 through a closed approach. Osteotomies were necessary in 56 patients. Mean follow-up was 13 months (range, 9-16 mo). A satisfactory result was achieved in all but 3 patients who had visible irregularities. Two of them required minimal rasping under local anesthesia and the third patient refused any further treatment.

CONCLUSIONS

Our modification of Skoog's original technique has certain advantages: the hump acts as a spreader and onlay graft, which preserves the natural dorsal lines. The sutures increase the nasal valve angle while preventing displacement of the reinserted hump. Indications include a straight or mildly deviated nose, a long thin-skinned nose with short nasal bones. The technique is also feasible through the closed or open approach and offers a valuable alternative to spreader grafts or flaps.

Effects of Spreader Grafts on Olfactory Function in Septorhinoplasty

BACKGROUND

Following rhinoplasty, the cross-sectional parts of the nose may be significantly reduced, and nasal air movement and olfaction may be altered. Studies on olfactory function after surgical procedures are quite limited and have largely focused on sinus surgery or septoplasty.

OBJECTIVES

The objective of this study is to assess the consequences of spreader grafts on olfactory function.

METHODS

This prospective study was conducted at the Gaziosmanpaşa Taksim Education and Research Hospital, Department of Otolaryngology, from January 2014 to June 2015. In total, 68 patients who had undergone an open-technique septorhinoplasty were included. In 35 patients, bilateral spreader grafts were included with the open septorhinoplasty (group 1), and 33 patients underwent open septorhinoplasties without spreader grafts (group 2).

RESULTS

The age and gender distributions of the patients in the two groups did not differ (p > 0.05). Preoperative threshold, discrimination, and identification values in both groups did not differ (p > 0.05). In groups 1 and 2, postoperative threshold values were significantly higher than preoperative values (p < 0.05). The change in threshold, discrimination, and identification level was significantly higher postoperatively versus preoperatively in group 1 (p < 0.05); however, the changes in discrimination and identification values did not significantly differ between in group 2 (p > 0.05).

CONCLUSIONS

Our study demonstrates the superior widening effect of spreader grafts over the nasal valve and favorable results in olfactory function in primary septorhinoplasty patients.

LEVEL OF EVIDENCE IV

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