Upper lateral strut graft: a technique to improve the internal nasal valve

Chondrocutaneous Custom-made Graft for Upper Lateral and Alar Cartilage Nose Reconstruction: The T Graft

Upper lateral cartilage and alar cartilage nose reconstruction secondary to failed aesthetic procedure or tumor excision, surely represents a reconstructive challenge for plastic surgeons, because of the support needed and for the function of the internal nasal valve (INV). Several scientific publications deal with internal nasal reconstructive techniques, including simple homologous or heterologous tissue grafts. We describe a new hybrid chondrocutaneous graft used for reconstruction of the upper lateral cartilage and a portion of the alar cartilage (cephalic part), excised with the adherent nasal mucosa (in correspondence with INV), included in the tumor mass.

The Impact of Scroll Ligament Preservation on Nasal Airway Patency in Rhinoplasty: An Objective Study with Rhinomanometry and Acoustic Rhinometry

BACKGROUND

Rhinoplasty is a critical surgical intervention aimed at enhancing nasal form and function. However, traditional approaches often compromise the integrity of nasal scroll ligaments, vital for the functionality of the internal nasal valve, leading to potential postoperative nasal dysfunction. Despite the importance of scroll ligaments in maintaining nasal structure and function, the literature lacks objective, quantifiable evidence of their role. This study sought to objectively compare nasal functionality and anatomy between patients undergoing rhinoplasty with bilateral preservation of scroll ligaments and those with bilateral sacrifice of these ligaments, employing computerized rhinomanometric and acoustic rhinometric measurements as evaluative tools.

METHODS

This retrospective, double-blind study was conducted at Tekirdağ Namık Kemal University's Plastic Reconstructive and Aesthetic Surgery and Ear, Nose, and Throat Clinics. The study population comprised patients who underwent rhinoplasty between May 1, 2018, and October 1, 2019. Patients were rigorously selected based on their medical history, including previous nasal surgeries, aesthetic dissatisfaction, and minimal nasal septum deviation. They were then categorized into two distinct groups: one undergoing rhinoplasty with an emphasis on preserving the scroll ligaments (n = 31) and the other where these ligaments were intentionally sacrificed (n = 30). A comprehensive analysis involving preoperative and six-month postoperative computerized rhinomanometry and acoustic rhinometry measurements was conducted to assess the surgical impact on nasal functionality and structure. The statistical comparison focused on evaluating the changes in air pressure and airflow rates, aiming to delineate the functional outcomes attributable to the differing surgical techniques.

RESULTS

Our findings reveal a stark contrast in postoperative nasal functionality between the two groups. In the group with preserved scroll ligaments, there was a significant improvement in postoperative computerized rhinomanometric measurements, indicating enhanced nasal airflow and reduced airway resistance. Conversely, the group with sacrificed scroll ligaments exhibited deteriorated postoperative outcomes, with increased nasal airway resistance and decreased airflow. These differences underscore the pivotal role of scroll ligaments in maintaining nasal airway patency and functionality.

CONCLUSION

The study unequivocally demonstrates that the preservation of scroll ligaments during rhinoplasty significantly benefits nasal airway function, as evidenced by improved postoperative rhinomanometry and acoustic rhinometry measurements. This objective data provide a compelling argument for the functional importance of scroll ligaments, advocating for surgical techniques that prioritize their preservation. By highlighting the positive correlation between ligament preservation and enhanced nasal functionality, this research contributes valuable insights into rhinoplasty practices, suggesting a paradigm shift towards approaches that safeguard nasal structural integrity for optimal functional outcomes.

LEVEL OF EVIDENCE IV

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Three-dimensional image study of accelerated maxillary expansion in oral breathing kids

OBJECTIVE

To evaluate, by a three-dimensional study, the volumetric and integumentary effects of rapid maxillary expansion on the nose, in mouth breathing kids with maxillary hypoplasia, in the short term, assessing the possible interference of gender, growth and age on the results achieved.

METHODS

120 mouth breathing patients with maxilla hypoplasia were divided into an Experimental Group treated by rapid maxillary expansion (n = 104, 62 males and 42 females, mean age 10.1 years, SD = 2.10, ranging from 5.1 to 13.9 years); and Control Group, constituted by 16 patients (9 males and 7 females, mean age 9.3 years, SD = 2.1 years, ranging from 6.1 to 13.2 years). Patients in the experimental group underwent multislice computed tomography examinations at two different times: (T1) pre-expansion and (T2) post-expansion. The control group was submitted to the same tests at the same time intervals. Six soft tissue variables of the nose were studied, besides the volume and area of the nasal cavity, and the measurement and comparison of data between T1 and T2 were performed using the Dolphin Imaging 11.7 Premium software.

RESULTS

The experimental group showed significant mean increases in all soft tissue variables studied (p < 0.005), yet there were no significant changes in the control group. In the comparison between groups, only inclination of the nasal dorsum did not present any significant change.

CONCLUSION

Rapid maxillary expansion may alter the nasal shape and physiology, by anatomical changes in the nose soft tissues, making it an important aid in the treatment of mouth breathing in childhood.

LEVEL OF EVIDENCE

The soft tissues of the nose play an important role in nasal shape and physiology and facial esthetics, and since they are directly related to the nasal valves, they are fundamental for maintenance and stability of the nasal breathing pattern.

Assessment of Vertical Triangular Spreader Graft Technique for Reconstruction of Middle Vault and Internal Nasal Valve Angle

BACKGROUND

Rhinoplasty is a surgical procedure to smooth out the nasal deformities and to fix nasal breathing problems. Spreader grafts and flaps are used to prevent some complications such as middle vault collapse, narrowing the internal nasal valve and inverted V deformity. To obtain more stable middle vault, spreader grafts and flaps could be used together. Many researchers have tried different graft and flap techniques to reach more successful aesthetic and functional results. In this research, we investigated effects of triangular graft on the internal nasal valve angle, nasal breathing, and aesthetic outcomes when it used together with sprader flap.

METHODS

In this prospective study, 3 different groups were formed as: the spreader flap group (group 1); the spreader flap with the rectangular spreader graft group (group 2); and the spreader flap with the triangular spreader graft group (group 3). Preoperative nasal obstruction symptom evaluation (NOSE) scale was used to evaluate nasal breathing and visual analog scale (VAS) was used to evaluate aesthetic appearance. And also, measurement of the internal nasal valve angle was performed for each patients. These evaluations were repeated at postoperative 3rd month. Preoperative and postoperative comparisons between study groups were performed.

RESULTS

There were 12 patients in group 1, 14 patients in group 2, and 10 patients in group 3. In each group, statistically significant decrease in NOSE scores (P < 0.05) and statistical significant increase in VAS scores (P < 0.05) were observed. And also, increased internal nasal valve angle after surgery was detected in all groups (P < 0.05). Postoperative NOSE and VAS scores were found similar in 3 different groups (P > 0.05). On the contrary, the internal nasal valve angles were found statistically significant increased in group 3 according to other groups (P < 0.05).

CONCLUSION

The results of this prospective study presented that the use of triangular spreader graft with spreader flap was an appropriate technique to obtain successful aesthetic and functional outcomes with widening the internal nasal valve angle.

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.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Acoustic rhinometry and video endoscopic scoring to evaluate postoperative outcomes in endonasal spreader graft surgery with septoplasty and turbinoplasty for nasal valve collapse

BACKGROUND

Nasal obstruction is a common complaint seen by otolaryngologists. The internal nasal valve (INV) is typically the narrowest portion of the nasal cavity, and if this area collapses on inspiration the patient experiences significant symptoms of nasal obstruction. The nasal obstruction is further compounded if the INV is narrower than normal. Previous studies have evaluated the effectiveness of techniques to alleviate structural nasal obstruction, but none have looked specifically at spreader grafts measured by acoustic rhinometry or validated grading assessment of dynamic INV collapse. Our objective was to evaluate the application of acoustic rhinometry coupled with visual endoscopic grading of the INV, and validated subjective measurements, in patients undergoing endonasal spreader graft surgery with septoplasty and turbinoplasty.

METHODS

This is a prospective clinical study conducted within a tertiary care rhinoplasty practice. Patients undergoing septoplasty and bilateral inferior turbinoplasty with bilateral endonasal spreader graft placement for observed internal nasal valve collapse were recruited. Baseline, early and intermediate postoperative measures were obtained. The primary outcome was grading of the INV collapse on video endoscopy. Secondary outcomes included cross-sectional area at the INV measured by acoustic rhinometry, subjective Nasal Obstruction Symptom Evaluation (NOSE) and Sino-Nasal Outcome Tool (SNOT-22) scores.

RESULTS

A total of 17 patients, average age of 34.5 ± 12.2 years, undergoing septoplasty, bilateral endonasal spreader grafts, and bilateral turbinoplasty were included in the study. Postoperative measurements were performed at an average of 8.1 ± 1.6 weeks and 17.7 ± 4.2 weeks. Patients had significant improvement for INV collapse grading, cross-sectional area, NOSE and SNOT-22 scores in both the early and intermediate follow up. Endoscopic grading had moderate inter-rater agreement (κ = 0.579) and average intra-rater agreement (κ = 0.545).

CONCLUSIONS

This study is the first to demonstrate a statistically significant improvement of objective measurement of internal nasal valve function, both static and dynamic, and subjective improvements. This supports endonasal cartilagenous spreader grafts with septoplasty and inferior turbinoplasty for patients with nasal obstruction with internal nasal valve collapse.

Anatomy of the upper lateral cartilage along the lateral pyriform aperture

BACKGROUND

The upper lateral cartilages underlie the nasal bones cephalically, and articulate with the nasal septum medially. The authors studied the histologic and anatomical relationships between the lateral aspect of the upper lateral cartilages and the frontal process of the maxilla.

METHODS

Six cadaver noses were dissected by open rhinoplasty to expose the upper lateral cartilages bilaterally. Subperiosteal dissection was performed over the medial maxillae and nasal bones to expose the perimeter of the pyriform aperture. Twelve sides were analyzed anatomically. Three cadavers were used to create six tissue specimens for histologic analysis, by resecting the tissue of the upper lateral cartilage-maxillary bone articulation en bloc.

RESULTS

Grossly in all specimens, the upper lateral cartilage articulated with the frontal process of the maxilla laterally, lying deep to the coronal plane of the maxillary bone. In four histologic specimens, the upper lateral cartilage was found to underlie the frontal process of the maxilla laterally, displaying an overlapping relationship. In the other two histologic specimens, the upper lateral cartilage ended medial to the maxilla. In all specimens, the ends of the upper lateral cartilage and maxilla articulated by way of a pyriform ligament.

CONCLUSIONS

The upper lateral cartilage articulates laterally with the frontal process of the maxilla by means of the pyriform ligament, with a variable amount of overlap between the upper lateral cartilage and maxilla. Relationships among the upper lateral cartilage, maxilla, and pyriform ligament affect the configuration of the lateral internal nasal valve area, and should be considered when planning internal nasal valve reconstruction.