Update in the management of the middle vault in rhinoplasty

Nasal Sidewall Dimensions in the Asian Nose: A Thai Cadaveric Study

Nasal bone length remains a commonly referenced attribute when referring to the aesthetic nose. Short nasal bone length is suggested to predispose to a greater risk of middle vault collapse after rhinoplasty. We report on normative measurements of nasal bones and associated structures in Thai cadavers. Using twelve adult cadavers, common external nasal landmarks were identified and measured to approximate the dimensions of the nasal bones and upper lateral cartilages. These clinically relevant surface landmarks were correlated to direct measurements of dissected nasal bones and the upper lateral cartilage in these same cadavers. Additionally, external landmarks of ten volunteers were examined. The average measured length of the nasal bone was 19.00 mm; the average measured length of the upper lateral cartilage was 13.15 mm. Measurements obtained via external landmarks were 17.60 mm and 13.05 mm respectively. The relationship of the nasal bone internal length to the external measurement (A) was a ratio of 1.10:1, whereas the internal length of the upper lateral cartilage to the corresponding external measurement (B) was 1.04:1. On average the nasal bones contributed to 59% of the middle vault nasal sidewall. The average length of the Thai adult nasal bone is 19.00 mm while that of the upper lateral cartilage is 13.15 mm. The relationships of the accepted external landmarks to the underlying anatomic structures were established using a t test. This normative data will generate useful parameters when evaluating the Asian rhinoplasty patient.

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.

Diagnostic Algorithm for Evaluating Nasal Airway Obstruction

Nasal obstruction is a common symptom and can have a large impact on patient quality of life. There are numerous causes, including anatomic, congenital, inflammatory, infectious, neoplastic, toxic, and systemic. An algorithmic approach can aid in ensuring all pertinent patient information is incorporated into the final diagnosis and treatment plan. Key components include a thorough history, physical examination including modified Cottle and Cottle maneuver, patient-reported outcome measures and/or quality of life questionnaires, examination with and without decongestion, and nasal endoscopy. The resultant information can then be effectively used to narrow the differential and guide the next steps in management.