The osseocartilaginous vault of the nose: anatomy and surgical observations

Management of the Crooked Nose: Structural, Preservation, or Camouflage Techniques

The asymmetric nose is challenging for even the most experienced rhinoplasty surgeons. It has often been referred to as the crooked, twisted, and deviated nose and describes any nose that has deviation of the nasal dorsum and pyramid from the facial midline. This article summarizes the senior author's (SPM) approach and application of structural and preservation concepts to correct the underlying causes of the crooked nose.

Dorsal Preservation Versus Structural Techniques and Their Application

Structure rhinoplasty and preservation rhinoplasty are 2 popular philosophies that can be used alone or in combination to provide a hybrid approach. Structure rhinoplasty is the leading option for revision rhinoplasty and utilizes cartilage grafting techniques to support and reconstruct the nose. Preservation rhinoplasty spares bone, cartilage, ligaments, and soft tissues to minimize the need for grafting and preserves the favorable features of the nose. Structural preservation rhinoplasty uses dorsal preservation in the upper two-thirds of the nose and structure rhinoplasty in the lower third. This hybrid approach has great utility in primary, revision, and reconstructive rhinoplasty.

Dorsal Preservation versus Component Dorsal Hump Reduction Rhinoplasty: An Assessment of Patient-reported Outcomes

Background

The literature on patient-reported outcomes (PROs) discussing dorsal preservation rhinoplasty (DPR) and component dorsal hump reduction (CDHR) is scarce. This study aims to fill the gap in PROs between these techniques.

Methods

A systematic review was conducted to investigate PROs of DPR and CDHR. A proportion meta-analysis was conducted using Stata statistical software.

Results

A total of 25 studies met our inclusion criteria, pooling 1706 participants, with 13 studies on CDHP and 12 studies on DPR. Overall satisfaction rates were high, varying from 84% to 100% across studies. A subgroup analysis revealed that both techniques exhibited equally high satisfaction with no statistical differences (P = 0.18). A random-effects model revealed that about two of 100 treated patients underwent revisions across our cohort (95% interquartile range: 0-4). Notably, the CDHR technique was associated with a significant 53.7-point reduction in the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS)-cosmetic domain [95% confidence interval (CI): -62.7 to -44.8, P < 0.001], along with a meaningful improvement in SCHNOS-obstructive scores by -27.3 points (95% CI: -50.5 to -4.04, P = 0.02). Conversely, the DPR was linked to a 55.3-point reduction in the SCHNOS-cosmetic domain (95% CI: -60.7 to -49.9, P < 0.001), and a -19.5 point change in the SCHNOS-obstructive domain (95% CI: -27.9 to -11.1, P < 0.001).

Conclusion

Although PROs are comparable, the literature suggests that CDHR outcomes may be better than DPR in alleviating obstructive symptoms, potentially offering an evidence-based choice for addressing functional concerns in rhinoplasty.

Preservation Rhinoplasty by the Ones Who Do It: A Worldwide Survey

Dorsal preservation (DP) rhinoplasty techniques, including surface techniques (STs) and foundation techniques (FTs) have garnered significant attention internationally over the past few years. The practice patterns and opinions from 117 of these surgeons were surveyed from a cohort of these surgeons who participate in an online Evidence-Based Rhinoplasty Research Group. The findings of the survey are merely a snapshot of the international rhinoplasty community's practices, yet did capture data from surgeons from a diverse geographic, years of experience, and training background. STs were most used for the bone changes, and the high-strip technique was preferred for the cartilaginous septal surgery. STs are mostly performed by younger surgeons (<10 years of experience), whereas FTs were more common in older surgeons (10-30 years of experience). STs were considered more stable (p < 0.001), more predictable (p < 0.001), and associate with a shorter learning curve (p = 0.015). Revision surgery rates were not different. Regarding why many surgeons using DP still perform structural rhinoplasty, the most cited concern was hump persistence/recurrence. In summary, among surgeons using DP rhinoplasty techniques, the majority perform DP in over half of their primary rhinoplasty surgeries, highlighting the importance of updating educational programs in medical training, conferences, and courses.

Hybrid Dorsal Preservation Rhinoplasty: Reediting an Aesthetic Dorsum

BACKGROUND

The prerequisite of a well-shaped dorsum with proper dorsal aesthetic lines that needs no modifications in its width and symmetry is key to letdown and push-down techniques as classically described. The common current concept is that total preservation of the middle vault is obligatory. This, however, obviously limits the indications, since nasal dorsum with natural aesthetic dorsal lines per se is relatively few. The recent, impressive, revival of letdown and push-down procedures has progressively generated numerous technical variations, but all those essentially still left the middle vault unmodified. The concept of splitting the middle vault and modifying its width and symmetry, while leaving the crucial dorsal (central) and lateral Keystone area intact, represents a new hybrid approach to the nasal dorsum. The structural benefits of classical component separation are combined with the major advantage of preserving the flexible chondro-osseous joint at the keystone junction. Osteotomies and/or osteoplasty can be done as necessary to modify the bony dorsum and at the same time any type of septal deformity can be addressed according to the time-tested L-strut principle, a Cottle septoplasty included. This hybrid approach expands indications beyond those of the conventional push-down/letdown technique, including moderate asymmetries of the bony and cartilaginous dorsum. Although splitting the middle vault along the septal T will also facilitate middle vault reshaping in cases where a full letdown procedure is indicated, this paper will clarity address only those instances where no circumferential osteotomy is done.

METHODS AND MATERIALS

The dorsal bony nasal pyramid is always addressed first by rhinosculpture (osteoplasty) with piezoelectric inserts and/or burrs, in combination with different types of osteotomies as needed. This will allow narrowing of the bridge and correction of bony asymmetries. The osseous-cartilaginous connection of the central dorsal keystone area (DKA) is totally preserved. At this point, three main variations are possible: Type 1) preservation of the septal T and push-down by a high-middle septal strip resection, two different variations (1A and 1B) are possible here, Type 2) reduction in width of the septal T-segment and middle vault restoration by spreader flaps without any push-down of the septal T and Type 3) preservation of the septal T and letdown by low strip resection.

CONCLUSION

Hybrid Dorsal Preservation involves concepts of Structure and Preservation Rhinoplasty. Dorsal and lateral keystone area are preserved, and the middle vault could be modified splitting the septal T in the anatomical plane, expanding patient indications and improve outcomes.

LEVEL OF EVIDENCE V

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 .

Precision Rhinoplasty Cylindric Burrs-Sidewall Aesthetics

The development of power instruments has led to great advances in rhinoplasty. It has helped to reduce operating time, minimize damage to the surrounding soft tissues, and allow precision bony modification compared with the use of manual rasps. Burrs help ensure precise results by (i) creating a smooth transition between the lateral nasal sidewall and the face, (ii) treating bony asymmetries, and (iii) producing homogeneous upper and middle thirds that softy translate into the upper lateral cartilages. The aim of this paper is to show applications of cylindrical burrs in rhinoplasty surgery to treat the dorsal upper and middle thirds as well as lateral sidewalls of the nose, regardless of whether the dorsal preservation or structure technique is used. This approach offers a safe, fast, and precise technique that can be used in conjunction with piezo osteotomy to obtain the optimal outcomes.

The relay graft, a tailored supplement between the nasal hump and established tip in East Asian rhinoplasty

BACKGROUND

In East Asian individuals, the nasal bone already has sufficient height for an ideal dorsal profile, but the tip requires enhancement for a desired projection. Consequently, the gap between the intrinsic bony structure and the established nasal tip requires appropriate management. The options are either to reduce the keystone region to create a smooth bed for a conventional dorsal onlay graft or to preserve the original osseocartilaginous structures and then customize a supplementary graft. The aim of this study was to detail and validate the utilization of a relay graft, a transition graft that fills the structural gap between the upper dorsum and established tip graft. The proper application of this graft could prevent osteotomy and preserve the intrinsic dorsum.

METHODS

Relay grafts were applied during rib-based rhinoplasty in East Asian patients. Three-dimensional stereophotogrammetric evaluations of the patients were performed. Anthropometric points were analyzed in a blinded fashion. Outcome variables were tip projection improvement, radix elevation, and the angulation of kyphion and pronasale.

RESULTS

Fifteen female patients, ranging in age from 21 to 40 years (average 24.5 years), were included. In all cases, the relay graft was applied as one essential element for filling the structural gap. No crooked dorsal profile or visible graft was noted in all cases. Fifteen patients completed the pre- and postoperative stereophotogrammetric study. Postoperative analysis showed great improvement of tip position as well as a slight elevation of the radix, evidenced by the consistent change of kyphion/pronasale angulation and sellion elevation.

CONCLUSIONS

The relay graft effectively mitigates the necessity of a disruptive dorsal reduction. It is entirely possible for East Asians to achieve a smooth dorsal profile when only the lower half of the dorsum is transitioned to the proposed tip position.

LEVEL OF EVIDENCE

Level IV, case series.

Saudi Population Nasal Anthropometric Study: Local and International Comparison

Anthropometric measurements are essential for diagnosing and treating various craniofacial disorders during nasal reconstruction and esthetic surgery. Different people have unique individual esthetic features that are a mixture of different races and backgrounds. This study aimed to compare 12 different anthropometric measurements in the Saudi Arabian population with those in other local and international studies. This cross-sectional study was conducted with 420 volunteers from December 2022 to August 2023 in Riyadh, Saudi Arabia. Study samples were drawn from the general population, and 12 nasal anthropometric variables were measured, including 7 linear and 5 angular variables, by taking digital photographs from frontal and lateral views. Anthropometric landmarks and measurements were obtained as previously described by Farkas et al. Photographs were analyzed using Adobe Photoshop CS4 software, and facial landmarks were identified. Data were analyzed using an independent sample t test to assess the mean and SD with differences (P<0.05 indicated a significant value). After statistical analysis, the results were compared with previously published standards for other races. Exactly 420 Saudi Arabian volunteers were examined to compare nasal anthropometric variables. All 12 nasal anthropometric variables differed significantly between male and female individuals. Anthropometry of the nose has an enormous miscellaneous relationship between sexes and populations of different geographic areas. It is important to create average anthropometric measurements for different groups for successful plastic surgery and rhinoplasty.

Advanced Preservation Rhinoplasty in the Era of Osteoplasty and Chondroplasty: How Have We Moved Beyond the Cottle Technique?

BACKGROUND

Over the last 10 years, many new papers on innovative strategies from different surgeons worldwide have elevated the philosophy of preservation rhinoplasty (PR) to a different level: advanced preservation rhinoplasty.

OBJECTIVES

The goal of this article was to illustrate how 4 experienced surgeons approach important anatomical and functional issues related to PR.

METHODS

M.G.F., A.M.K., B.S., and D.M.T. were asked about how they approach classical problems and relative contraindications for dorsal PR with different modern advanced preservation rhinoplasty techniques.

RESULTS

The answers of each surgeon make clear a new reality in dorsal PR that did not exist in the recent past. These advances in dorsal PR techniques are due to many surgeons' contributions, leading this practice to a different level: advanced preservation rhinoplasty.

CONCLUSIONS

Dorsal preservation is making a dramatic resurgence and is fueled by the many very talented surgeons who are demonstrating outstanding outcomes with preservation techniques. The authors believe that this trend will continue, and a mutual collaboration between structuralists and preservationists going forward will continue to advance rhinoplasty as a specialty.

Open Preservation Rhinoplasty

Preservation of native nasal structures in rhinoplasty has aesthetic and functional benefits. This ideology can be implemented within open surgical approaches and in the context of structural modifications of the nose, particularly the nasal tip (structural preservation). In addition, modifications of preservation techniques and hybrid approaches to the osseocartilaginous vault have resulted in expanded indications for preservation of the nasal dorsum. These modifications and indications, as well as septal management in preservation cases, are discussed here in the context of an open approach. Importantly, patient-reported measures suggest that both preservation and structural approaches can yield excellent outcomes. An understanding and integration of both techniques offer great versatility for the rhinoplasty surgeon.

Modified Dorsal Split Preservation Hybrid Rhinoplasty for Cartilaginous Pushdown and Full Letdown Applications: A PROM-Based Review of 100 Consecutive Cases

Splitting the middle vault on an anatomical plane along the "Septal T" allows a new hybrid perspective on the many modifications of "surface" preservation techniques. The "dorsal split preservation" concept can be applied both to cartilaginous pushdown as well as to full letdown techniques. The dorsal keystone area is maintained, while the middle vault is reshaped. The septum is addressed by conventional L strut septoplasty. Precise direct suture fixation of the high-middle strip is easily accomplished after flexing the osseous-chondral junction at the K area. Specific technical points are described to allow exact and stable configuration of the dorsum.A retrospective analysis on 100 consecutive patients demonstrated aesthetic and functional improvement.

Exploring the Resurgence of the Preservation Rhinoplasty: A Systematic Literature Review

INTRODUCTION

The underlying principles of preservation rhinoplasty (PR) center around maintaining the soft tissue envelope, dorsum, and alar cartilage through surgical manipulations and tip suture techniques. In particular, the let-down (LD) and push-down (PD) techniques have been described, although reports of indications and outcomes in the literature are sparse.

METHODS

A systematic review of the literature was performed using search terms "preservation" OR "let down" OR "push down" AND "rhinoplasty" on PubMed, Cochrane, SCOPUS, and EMBASE databases. Patient demographic information, operative details, and surgical outcomes were recorded. Sub-cohorts for patients who underwent LD and PD techniques were analyzed utilizing Fischer's exact test for categorical variables and Student's t test for continuous variables.

RESULTS

Overall, there were 5967 PR patients in 30 studies in the final analysis, with 307 patients in the PD cohort and 529 patients in the LD cohort. The Rhinoplasty Outcome Evaluation Questionnaire showed a significant increase of patient satisfaction after PR compared to before PR (62.13 vs 91.14; p < 0.001). There was a significantly lower rate of residual dorsal hump or recurrence of 1.3% (n = 4) in the PD when compared to 4.6% (n = 23) in LD cohorts (p = 0.02). The revision rate of PD (0%, n = 0) was also significantly lower than that of LD (5.0%, n = 25) (p < 0.001).

CONCLUSION

Based on these published articles, it seems that preservation rhinoplasty is safe and efficacious procedure with improved dorsal aesthetic lines, reduced dorsal contour irregularities, and claimed excellent patient satisfaction. In particular, the PD technique has fewer reported complications and revisions than LD approach, although PD is often indicated in patients with smaller dorsal humps.

LEVEL OF EVIDENCE III

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 .

Mobile Bony Cap (Meysem Yorgun Technique): An Innovative Technique in Preservation Rhinoplasty for Crooked Nose Deformity

Crooked nose deformity is a vertical axis deviation of the nasal pyramid; despite all advancements, it remains a significant problem to resolve. In this study, we present our I- and C-shaped crooked nose rhinoplasty results with this new osteotomy technique.

Methods

This study included 25 patients with I- or C-shaped crooked nose deformities who underwent correction with a closed-approach let-down procedure. In this technique, the middle vault is preserved, the bony cap is mobilized and preserved, and the lateral nasal bones are equalized by a piezo device or classical osteotomes. By the mobilization of the bony cap, tension on the dorsal septum is released, and slight asymmetries are hidden behind this mobile bony cap.

Results

The postoperative angles for both type I and C deformities were closer to the ideal angle, and the difference was statistically significant. All patients were satisfied with their aesthetic and functional results.

Conclusions

In this procedure, we correct asymmetries at the lower maxillary nasal junction, such as in the let-down approach, as well as asymmetries at the K-point, such as in the structural approach. Thus, we combine the advantages of both techniques. Additionally, the mobile-bony cap left on the patient is very useful for releasing the tension of the septal dorsum and hiding slight asymmetries that remain below in the patients.

Cosmetic Rhinoplasty

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Perform a systematic nasofacial analysis. 2. Identify the underlying anatomical cause of specific external nasal findings. 3. Recognize the interrelated effects of operative maneuvers. 4. Develop an appropriate operative plan to address patient concerns.

SUMMARY

The rhinoplasty operation is one of the most challenging procedures in plastic surgery, and requires a combination of surgical judgment, knowledge of anatomy, technical skill, and lifelong study. A foundation must be built on clearly defined patient goals and an accurate diagnosis, based on known ideals and their anatomical correlation. It is important to recognize the definitive impact of each operative maneuver to achieve predictable outcomes. This article provides a problem-based approach to common cosmetic nasal deformities.

Feminization Rhinoplasty

Facial gender affirmation surgery is currently growing worldwide and is an important treatment for gender dysphoria that will improve quality of life. The most frequently sought modifications by transgender women are forehead and supraorbital ridge reduction, cheek augmentation, upper lip surgery (lip lift), laryngeal chondroplasty, jaw reduction, and rhinoplasty. Rhinoplasty for transgender women uses the same techniques as rhinoplasty for a cisgender patient. However, knowledge of transgender care is necessary and must be widely adapted to all health professionals. This article intends to explain the author's personal approach to feminization rhinoplasty.

Using the septal shift technique to correct crooked nose deformity

BACKGROUND

Crooked nose deformity is defined as any degree of deviation of the anatomical structures involving the nasal bone, upper and lower lateral cartilages, and the septum from the midsagittal plane of the face, in any direction.

METHODS

This study introduces a new technique to correct crooked nose deformity. Twenty-six with I-shaped, C- and reverse C-shaped, and S-shaped crooked nose deformity underwent open approach rhinoplasty. After performing in-out fracture osteotomy, L-strut septoplasty was preferred. İnitially, the L-strut was sutured through the hole that opened to the maxillary spine and then passed to the dorsal section. In the dorsal part of the L-strut, a spreader graft with the appropriate thickness and length was sutured opposite to the deviated side, only at the keystone area. The L-strut was then incised vertically to form a cranial and caudal segment. The caudal portion was sutured by shifting to the other side of the spreader, beginning at the caudal end of the cranial portion. The upper lateral cartilages were sutured to the newly formed L-strut. Finally, tip plasty was performed, and the procedure was terminated.

RESULTS

The septal shift technique is an effective method for treating crooked nose deformity.

CONCLUSION

The septal shift technique is a new technique without complications used in our routine practice as an effective method for treating crooked nose deformity.

Trans-Nasion-Complex Approach for Endoscopic Modified Lothrop Procedure: Conception, Anatomy, and Technique

Background

The endoscopic modified Lothrop procedure (EMLP) is an important procedure used to address frontal and anterior skull-base lesions. Two techniques were established, namely, the inside-out approach and the outside-in approach. The former technique take the frontal recess and the first olfactory filament (FOF) as key landmarks while the latter use the FOF as posterior boundary. In some cases, however, these two landmarks are not available. Therefore, we supplement the outside-in approach and named it trans-nasion-complex approach (TNCA) for EMLP that can be performed without locating these two landmarks.

Methods

Two dry human skulls were used to observe the bony nasion complex. Then, five colored silicon-injected human head specimens were dissected via TNCA for EMLP. Finally, the outcomes of patients who underwent TNCA were reviewed.

Results

The nasion complex is an osseous complex that consists of the nasion and its adjacent structures, including the bilateral root of nasal bones, nasal process of frontal bones, anterior portion of the perpendicular plate of the ethmoid bone that connects with the inferior aspect of the nasal bones, and portions of the bilateral frontal process of the maxillary bones. Surgical landmarks for TNCA include the anterior superior portion of the nasal septum, anterior margin and axilla of the middle turbinate, frontal process of the maxilla bone, nasal process of the frontal bone and upper part of the nasal bone. These structures form a “mushroom sign” during cadaveric dissection and surgery. Twenty-one patients underwent TNCA, of whom 9 had tumors and 12 had chronic rhinosinusitis with nasal polyps (CRSwNP). None of them had major complications.

Conclusion

TNCA is expected to be a safe, and direct route for EMLP. Adequate understanding of the nasion complex and “mushroom sign” will be helpful to complete TNCA.

Comparison of the Effect of Spreader and T-Splay Graft in Internal Nasal Valve Management

BACKGROUND

The midvalve area is one of the most important anatomical points in rhinoplasty procedures. An additional intervention may be required to ensure there is no narrowing in this region. For this reason, several different techniques are used. Spreader graft technique is the most common of all these methods. T-splay graft technique is an alternative method that can effectively widen the angle of the midvalve. The present study compares the anatomical and functional outcomes of these two methods.

METHODS

The study included 60 cases who presented to our clinic for rhinoplasty. The cases were evaluated demographically, anatomically, and functionally, and the acquired data were recorded. All cases were preoperatively administered the Visual Analogue Scale, the Nasal Obstruction Symptom Evaluation scale, and the modified Glatzel mirror test. By randomly selecting the cases, midvalve restoration was performed with a spreader graft in 30 cases and a T-splay graft in 30 cases.

RESULTS

A comparison of the Visual Analogue Scale, the Nasal Obstruction Symptom Evaluation scale, and the modified Glatzel mirror test scores revealed that the scores of both groups at postoperative months 3 and 6 were significantly different from the preoperative measurement values.

CONCLUSIONS

Although spreader graft technique is a very effective method in midvalve management, we believe that T-splay graft technique may also produce effective outcomes. In addition, the midvalve functions could be better simulated anatomically and functionally with T-splay graft technique. Therefore, we believe that T-splay graft technique is an alternative method that can be safely used in selected cases.

LEVEL OF EVIDENCE III

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 .

A 3-Level Impaction Technique for Dorsal Reshaping and Reduction Without Dorsal Soft Tissue Envelope Dissection

BACKGROUND

Preservation rhinoplasty (PR) techniques are continuously evolving and many variations of established techniques have been proposed since Daniel coined this term in 2018.

OBJECTIVES

The aim of this study was to describe indications for a new "3-level impaction" technique, allowing, in selected cases, a complete profile correction and dorsal reduction without dissection of the dorsal soft tissue envelope (STE).

METHODS

Three hundred and fifty primary closed rhinoplasty cases were retrospectively studied from January 2018 and October 2019. Age, sex, race, technical details, surgical time, and complications were registered. Ninety-five dorsa were reduced and shaped without dissecting the dorsal STE by combining: (1) a swinging-door septoplasty with low septal strip resection, (2) endonasal bony cap mosaic osteotomies, and (3) let-down or push-down operation.

RESULTS

All patients showed a dramatic change in profile height and shape without either dorsal STE dissection or bony cartilage dorsal tissue resection. Mosaic osteotomies converted the dorsal keystone area from S- to V-shaped dorsum, let-down-operation and low septal strip resection enabled impaction, and profile setting was achieved by quadrangular cartilage flap rotation. The average follow-up time was 14 months (range, 12-16 months).

CONCLUSIONS

In selected patients, dorsum can be preserved without STE dissection. By combining multiple endonasal maneuvers it is possible to obtain a dramatic change without dissecting the STE, while simultaneously avoiding any dorsal tissue resection. This method offers a versatile technique in selected patients, which leads to fast recovery and natural results.

LEVEL OF EVIDENCE: 4

Combining Open Structural and Dorsal Preservation Rhinoplasty

There has been a resurgence in dorsal preservation rhinoplasty (DPR) caused by theoretic aesthetic and functional advantages compared with conventional hump takedown rhinoplasty. Classically, the push-down and let-down maneuvers have been described for management of the bony nasal vault. There have been a variety of modifications in the septal resection that is a requisite for dorsal lowering in DPR. Partial dorsal preservation techniques, including cartilage-only preservation, have also been described. Although several studies have reported aesthetic and functional success with a variety of techniques, few have used objective or patient-centered subjective measures.

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 .

Ambiguous "olfactory" terms for anatomic spaces adjacent to the cribriform plate: A publication database analysis and quest for uniformity

A precise nomenclature and terminology is the foundation of communication in Anatomy and related biomedical sciences. The olfactory bulbs and nerves lie above and below the cribriform plate (CP), respectively. Hence, many anatomical landmarks in this region have names adopting the term "olfactory" as qualifiers. Ambiguous use of these "olfactory" terms exists, with some potential repercussions on patient treatments. We performed a publication database analysis to determine the frequency of misuse of names for seven anatomical "olfactory" spaces close to the CP and nasal cavity. We searched PubMed® publications having the keyword "olfactory" in their title or abstract, plus one of seven other keywords: "groove", "fossa", "recess", "cleft", "vestibule", "sulcus", and "cistern". We reviewed all abstracts for accuracy of these terms relative to accepted norms or customary definitions. By February 2020, we found all these keywords in 1255 articles. For the terms olfactory "groove" and "fossa", the number of relevant articles (and percentage of those inaccurately using these terms) were 374 (1.1%), and 49 (8.2%), respectively. All 52 abstracts containing "olfactory" and "vestibule" were irrelevant, relating to the "nasal vestibule" and olfactory function, instead of "olfactory vestibule". Overall, terms used to describe "olfactory" spaces near the CP are seldom ambiguous or inaccurate, but the terms olfactory "groove" and "fossa" are occasionally misused, We propose several new "olfactory" terms for inclusion in the Terminologia Anatomica, and stress the need for uniform nomenclature leading to greater consistency and accuracy in clinical use of anatomical terms containing the word "olfactory" as a descriptor.

Airflow Considerations and the Effect of Webster's Triangle in Reduction Rhinoplasty

BACKGROUND

Reduction rhinoplasties, regardless of the methods used (structural or preservation), can cause a reduction in the internal nasal volume, which may lead to breathing problems. In 1977, Webster proposed preserving a little triangle in the beginning of the lower lateral osteotomy line to prevent breathing problem. However, its importance is still controversial.

OBJECTIVES

and methods: This prospective randomized controlled study (level of evidence 1) included 46 patients without nasal breathing problem. High-to-low (Webster's triangle preservation) osteotomy (control group, n = 23) and low-to-low osteotomy (study group, n = 23) were performed. All operations were performed according to the proposed volumetric rhinoplasty steps (examination/measurement, prevention and treatment). Nasal obstruction symptom evaluation (NOSE) test, visual analog scale, acoustic rhinometry, rhinomanometry, peak nasal inspiratory flow (PNIF), and three-dimensional measurements were performed in all patients. Breathing tests were repeated before and 6 months after surgery with and without xylometazoline administration.

RESULTS

No statistically significant difference in NOSE and visual analog scale scores was found between the two groups. Acoustic rhinometry, PNIF, and rhinomanometry findings showed no statistically significant breathing difference between the two groups.

CONCLUSIONS

In reduction rhinoplasties, a decrease in the internal volume may be expected as directly proportional with the reduction amount. The decrease in the internal volume may create nasal breathing problems. To prevent it, nasal airflow should be adjusted according to new anatomy. In this study, we discussed "volumetric rhinoplasty" steps to prevent breathing problems in reduction rhinoplasty. Following these steps, not preserving Webster's triangle (low-to-low osteotomy) has no effect on the nasal airway.

LEVEL OF EVIDENCE II

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 .

Addressing the Upper Third of the Nose in Endonasal Rhinoplasty

Effective management of the upper nasal vault is based on a thorough preoperative analysis and detailed understanding of the requisite principles and techniques utilized to modify the anatomic structures in this region. The surgeon must equally consider form and function when performing manipulation of the upper nasal vault. Special considerations apply when managing this anatomic region via an endonasal or closed approach. A review of this topic is presented with a focus on techniques as they apply to the endonasal rhinoplasty patient.

Laser-Assisted Rhinoplasty: The Future Generation Rhinoplasty Technique to Preserve Anatomy? A Series of Patients Compared to Patients Undergoing Standard Open Rhinoplasty

BACKGROUND

Rhinoplasty is the cosmetic procedure that is most difficult to master. Anatomical preservation should represent the main goal of rhinoplasty. One emerging tool appears to be erbium:yttrium-aluminum-garnet laser bone and cartilage reshaping. The authors developed a new small laser hand probe to perform what we called laser-assisted rhinoplasty. The authors evaluate the feasibility of the laser-assisted rhinoplasty and the aesthetic and functional result of laser-assisted rhinoplasty compared to classic rhinoplasty.

METHODS

A total of 50 patients were enrolled and randomized into two cohorts: the first cohort of patients was submitted to classic rhinoplasty, and the second cohort to laser-assisted rhinoplasty. The laser beam was used to perform both the resection of the crura and the resection of the nasal hump and osteotomies.

RESULTS

Laser-assisted rhinoplasty is a safe and reproducible technique. At a clinical assessment, lateral crura reshaping showed a visible step or excessive skin retraction in 12 percent of the classic rhinoplasty population with thick cartilage and/or thin skin, and this was not present in the laser-assisted rhinoplasty population at 12-month follow-up. The patient satisfaction rate was higher in the laser-assisted rhinoplasty population compared with standard open rhinoplasty. The authors also clinically noted a reduction in edema in the immediate postoperative period in the laser-assisted rhinoplasty population and a more rapid complete resolution of the swelling.

CONCLUSION

The laser-assisted rhinoplasty technique is feasible and safe and has no major complication, and the aesthetic and functional results can be superimposed onto classic rhinoplasty but with a higher degree of intraoperative precision, higher patient satisfaction, a cleaner field, and less bleeding.

The Caucasian Hump: Radiologic Study of the Osteocartilaginous Vault versus Surface Anatomy. Clinical Implications in Structured and Preservation Rhinoplasty

BACKGROUND

The relation between the osteocartilaginous nasal vault and nasal hump characteristics has not been fully investigated.

METHODS

Measurements were collected from computed tomographic nasal scans in the midsagittal plane in adult Caucasian patients seeking rhinoplasty because of nasal hump from January of 2015 to December of 2018. Measurements were compared to those of sex- and age-matched patients not seeking rhinoplasty (control group). Patients with other significant nasal deformities were excluded. The correlations between nasal hump length, height, and osteocartilaginous nasal vault measurements were assessed. Distances from the beginning of the nasal hump to the kyphion and ethmoidal points were measured as well. The location of the nasal hump apex in relation to the keystone area structures was detailed.

RESULTS

The study included 134 Caucasian patients, with 67 presenting nasal hump. The mean patient age was 32.9 years and 69.6 percent were female patients. Nasal hump measured a mean 17 ± 2.7 mm in length and 1.8 mm (range, 1.1 to 3.8 mm) in height. Nasal hump length correlated with nose length and nasal bone length. Nasal hump height correlated with nose length and the angle over the kyphion. In 97 percent of patients, the nasal hump began caudal to the ethmoidal point, and in all patients, the kyphion was underneath the nasal hump. The nasal hump is not a symmetric structure and, in all patients, its apex was situated above the septal cartilage.

CONCLUSIONS

The nasal hump characteristics are mainly attributable to the septal cartilage, and this should be the cornerstone of any dorsal hump reduction strategy. The caudal aspect of the nasal bones contributes to the nasal hump, whereas the posterior ethmoidal plate rarely does.

Preservation Rhinoplasty: Assessment of Anatomical Safe Boundaries on Computed Tomography

BACKGROUND

Nasal dorsum reconstruction is a crucial step of the rhinoplasty. For avoiding complications, techniques that preserve natural dorsal anatomy becomes popular recently. In preservation techniques, ethmoidal bone surgery may take part in the vast majority of defined techniques. Therefore, detailed anatomical knowledge is essential to avoid severe complications, especially cerebrospinal fluid leakage. Based on these, this study aimed to investigate anatomical safe boundaries of preservation techniques based on the measurements on computed tomography.

METHODS

A total of 100 patients who underwent paranasal computed tomography were enrolled in this retrospective study. Five groups were selected based on the age distribution. The distance of the dorsal osteotomy line to cranial base, amount of cartilaginous/bony septum overlaps under nasal bones, cartilaginous/bony septum length anterior and posterior to the nasal hump starting point, and anteroposterior distance of perpendicular plate was measured.

RESULTS

The mean distance between the starting point of the nasal hump and the cribriform plate was 29.5 mm. The amount of bony overlap above the cartilaginous septum was 10.9 mm in females and 10.5 mm in males. The length of septal cartilage posterior to nasal hump was 0 mm in 39 of 100 patients (39%) and the mean value was 2.38 mm in all populations. The mean distance from the starting point of the perpendicular plate to the cribriform plate was 28.17 mm.

CONCLUSIONS

Perpendicular plate may take part in the constitution of the nasal hump. Therefore, delicate surgery with appropriate tools needed for avoiding the risk of skull base injury.

LEVEL OF EVIDENCE

Level of Evidence: 3 (Therapeutic).

Subdorsal Z-flap: a modification of the Cottle technique in dorsal preservation rhinoplasty

PURPOSE OF REVIEW

To present the novel technique of subdorsal Z-flap in dorsal preservation rhinoplasty and give an overview on current available dorsal preservation techniques in the literature.

RECENT FINDINGS

The subdorsal Z-flap combines the advantages of the high and low septal strip techniques in dorsal preservation rhinoplasty and ensures well tolerated treatment of the dorsal hump and structural stability.

SUMMARY

The technique and concept of Dorsal Preservation Rhinoplasty (DPR) has been used for more than a century but only recently gained significant popularity along with specific technical refinements. The advantage of DPR lies in the preservation of the delicate triangular cartilaginous unity of the septal and upper lateral cartilages with its functional and esthetic implications in contrast to all resecting techniques. A variety of modifications of DPR have been published in recent years, each with advantages and disadvantages. The issue of hump recurrence remains a major concern in DPR. We describe the 'subdorsal Z-flap' and related techniques of DPR in detail, present two clinical case studies and discuss alternative technical modifications. The 'subdorsal Z -flap' combines the advantages of the high septal strip procedure with the advantages of the traditional 'low septal strip' or Cottle technique. By starting the incision at a high level, final septal height can be adjusted precisely. By creating a triangular shape with a vertical cut below the K-Area, which is usually the highest point of the hump, significant leverage can be applied from below the hump and the septal overlap may be sutured securely for a stable correction. In combination with Piezo osteotomy and full open approach, great precision and predictability can be achieved. In a recent publication, we presented more than 100 consecutive cases of subdorsal Z-flap DPR with good functional and esthetic outcomes. The subdorsal Z-flap modification is a combination of two popular DPR techniques, fusing their advantages while minimizing risk profile. A slightly higher degree of technical difficulty and necessary tissue dissection provides the benefits of better predictability and reduction of adverse outcomes.

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 .

A Practical Classification System for Dorsal Preservation Rhinoplasty Techniques

Preservation rhinoplasty in general and dorsal preservation in particular are for sure one of the most attractive topics in modern rhinoplasty and probably the most puzzling concept in this field. Recent major meetings and many other publications have led to an increased interest in these old/new techniques. New strategies for preservation have been developed in recent years, with a broader range of indications than the older push/let down. A simple classification urges to clarify this puzzled semantic concept of "preservation". Is it possible to systematize all new preservation variations in a simple classification? Yes, in this viewpoint, we propose a simple classification that systematizes all kinds of preservation techniques-the old and the new techniques. Classifying preservation will clarify the relative position of all techniques. It will allow comparing procedures from similar families there so to compare outcomes and indications from each technique.

Cone-Beam Computed Tomography: A User-Friendly, Practical Roadmap to the Planning and Execution of Every Rhinoplasty-A 5-Year Review

BACKGROUND

Cone-beam computed tomography has recently rapidly developed worldwide as a versatile and convenient alternative to traditional computed tomography for imaging of the maxillofacial region. However, most surgeons performing rhinoplasty are surprisingly unfamiliar with it, in both the plastic surgery and ear, nose, and throat communities.

METHODS

The broad clinical experience of a single center over the past 5 years is reviewed. The many applications of cone-beam computed tomography to primary and secondary rhinoplasty are analyzed regarding septum, turbinates, nasal bones, skin thickness, and other issues. The importance of a paradigm shift from a two-dimensional to a three-dimensional approach in image reconstruction is demonstrated, together with the value of surface contour enhancement.

RESULTS

Cone-beam computed tomography has a multitude of practical applications highly relevant to rhinoplasty. The surface image will strengthen aesthetic analysis, and the detailed preview of bony and functional anatomy will facilitate surgical planning. Cone-beam computed tomography serves as a roadmap to plan and execute rhinoplasties more predictably and efficiently. The availability of spatial views and accurate detail, together with the possibility of easy, accurate measuring, offers a plenitude of potential applications.

CONCLUSIONS

Cone-beam computed tomography is a user-friendly, quick technique with abundant advantages in planning any rhinoplasty. It causes the patient no inconvenience and has very few, if any, drawbacks, with these being limited to radiation exposure and limited cost.

Middle Vault Changes After Humpectomy by Spare Roof Technique Versus Component Dorsal Hump Reduction

Objectives: To compare the effect of two different humpectomy techniques in the internal nasal valve (INV) angle in human anatomic specimens. Methods: Seven human anatomic specimens (14 heminoses) were included. A strip of subdorsal septal cartilage was removed and, in each nose, the right side of the middle roof lied intact over and was sutured to the septal cartilage (spare roof technique [SRT]), whereas in the left side the upper lateral cartilage was folded and sutured to the septal cartilage (component dorsal hump reduction [CDHR]). The INV angle was measured pre- and postoperatively. Results: Mean age of the specimens was 69.86 (60-80) years. Five were female. CDHR resulted in a mean change of +1.71 ± 3.12° (p = 0.197), +0.62 ± 6.89° (p = 0.817) and +6.97 ± 6.84° (p = 0.036) after resection of 2, 4, and 6 mm of septal cartilage, respectively. SRT resulted in a mean change of +1.27 ± 2.37° (p = 0.207), +6.89 ± 1.19° (p < 0.001), and +12.55 ± 1.79° (p < 0.001) after resection of 2, 4, and 6 mm of septal cartilage, respectively. In SRT, the amount of septal cartilage resection presented a significant correlation with change in INV angle (r = 0.813, p < 0.001). Conclusions: In this human anatomic study, SRT significantly increased INV angle.

120 Years of Dorsal Preservation in Rhinoplasty

Dorsal preservation techniques in rhinoplasty are experiencing a renaissance in recent years. New techniques and modifications to existing techniques are being described at an intensifying pace. Dorsal preservation, however, is not a new concept and was first described over 120 years ago. It is timely that we conduct a review of the key techniques and concepts of dorsal preservation in rhinoplasty that had been published over the past 120 years, at a moment in which we consider as a revival of this school of thought.

Incorporating Dorsal Preservation Rhinoplasty into Your Practice

For rhinoplasty surgeons, surgery of the dorsum has never been so dynamic or as easily learned. Reproducible techniques offer excellent results that can be difficult to achieve in certain patients using component reduction. An expanding repertoire of dorsal preservation (DP) techniques is evolving. Each DP operation builds on the others. To understand DP requires a new appreciation of the cartilaginous septum, the perpendicular plate of ethmoid, nasal osteotomies, and anatomy of the nose where surgeons do not operate with traditional component reduction. The result is more beautiful noses where the normal anatomy is preserved.

Conventional Resection Versus Preservation of the Nasal Dorsum and Ligaments: An Anatomic Perspective and Review of the Literature

Preservation rhinoplasty may refer to preserving several anatomic components including: the nasal bones, upper lateral cartilages, the keystone area and/or ligaments of the nose. Preserving the osseocartilaginous framework or "dorsal preservation" minimizes or completely avoids violation of the dorsal aesthetic lines' architecture. Conventional hump reduction in open rhinoplasty disrupts these lines; however, it also provides versatility to reshape the entire dorsum. Surgical success with either technique requires a thorough understanding of the underlying nasal anatomy.

Preservation Rhinoplasty and the Crooked Nose

Crooked or deviated noses pose a specific challenge as many of the elements in a deviated nose are not symmetric and therefore not ideal for preservation techniques. Deviated noses are often where a hybridization between preservation and structural rhinoplasty is required. Careful preoperative evaluation of the soft tissue and bony anatomy of the patient is very important and congenital or post-traumatic asymmetry may involve more than the nasal pyramid. Full exposure of the nasal pyramid allows for visualization and appropriate osteotomy or rhinosculpture.

Dorsal Preservation Rhinoplasty: Method and Outcomes of the Modified Subdorsal Strip Method

There has been particular recent interest in dorsal preservation rhinoplasty techniques because of claims of superior functional and aesthetic results relative to conventional hump reductions. The septum in dorsal preservation rhinoplasty is managed in a variety of ways with differences largely based on the location of septal excision (subdorsal resection, midseptal resection, and inferior septal resection). The technical considerations of a modified subdorsal strip method using a structural preservation technique are described. This technique maintains a subdorsal and caudal strut of cartilage. Patient-reported measures demonstrate significantly improved functional and aesthetic outcomes postoperatively with this procedure.

Expanding Indications for Dorsal Preservation Rhinoplasty With Cartilage Conversion Techniques

BACKGROUND

Preservation rhinoplasty (PR) is a new and evolving philosophy in rhinoplasty surgery. As a surgeon becomes more experienced with preservation concepts, he/she begins to look for new ways to apply PR to an increasing percentage of primary cases.

OBJECTIVES

This article presents a series of 100 primary rhinoplasties that underwent dorsal preservation with an emphasis on the cartilage-only dorsal preservation.

METHODS

A total of 226 primary rhinoplasty cases were studied retrospectively between July 2017 and August 2018. One hundred cases of dorsal preservation were included in the study. Data was collected in all cases regarding age, gender, ethnicity, and technical details of the operation. These 100 cases fall into the following 3 categories: (1) dorsal preservation employing a subdorsal strip; (2) dorsal preservation utilizing a cartilage-only pushdown with separate bony pyramid modification; and (3) dorsal preservation employing a cartilage reduction method with separate bony pyramid modification.

RESULTS

Fifty-seven patients underwent subdorsal strip technique, 39 underwent cartilage-only pushdown technique, and 4 underwent cartilage modification. The average lowering was 4.5 mm (range, 2-10 mm), 2.5 mm (range, 1-3.5 mm), and 2 mm (range, 1-2.5 mm) for the subdorsal strip, cartilage-only pushdown techniques, and cartilage modification technique, respectively. No patients required revision surgery of their dorsum.

CONCLUSIONS

PR is a paradigm shift in rhinoplasty. With time, surgeons will find themselves asking in every situation whether they can preserve structures. Dorsal preservation is a reliable technique if patients are chosen properly. With bony cap modification, more dorsums can be preserved and dorsal aesthetics can be improved.

LEVEL OF EVIDENCE: 4