Bilateral Fan-Shaped Septal Extension Struts in East Asian Augmentation Rhinoplasty

BACKGROUND

For costal cartilage-based rhinoplasty, a method that could properly manage warping of the columellar strut graft and facilitate establishing a stable cartilaginous framework remains desirable. In this study, the authors present a new graft design named bilateral septal extension strut. It utilizes a pair of cartilage grafts with the shape of a fan, which are bilaterally fixated to the septum. Such "sandwiched" structure undertakes the combined functional roles of a columellar strut and a septal extension graft.

METHODS

Fifty-two female patients, ranging in age from 18 to 37 years, received augmentation rhinoplasty surgery based on the bilateral septal extension strut. Among these patients, 20 of them were primary cases, 26 secondary, and other six cases were tertiary.

RESULTS

Patients' own evaluations on the overall improvements in the nose rendered high satisfaction rate. There was no case of graft extrusion or infections. During the long-term follow-up, one case presented dorsal onlay graft warping and two cases presented in significant asymmetrical nostrils due to the deviation of the columellar at 12 months postoperatively and were corrected in the revision surgery.

CONCLUSIONS

The application of the bilateral septal extension struts can help mitigate the negative impact of strut graft warping, making it more manageable. As a result, reliable as well as sustainable support for both tip and lower lateral cartilages can be achieved in the long term.

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 .

Comma-Shaped Columellar Strut for Nasal Tip Plasty in East Asian Rhinoplasty

BACKGROUND

For East Asians, rhinoplasty procedures are predominantly focused on reconstructing a well-defined nasal tip. In this study, the authors present a new graft design for the columellar strut that is similar to the shape of a comma mark. As one integrated piece, the graft undertakes the roles of providing solid support for the tip, modifying different angles, as well as relationships between the tip and columella.

METHODS

One hundred and sixty-five female patients, ranging in age from 18 to 42 years (average 27.1 years), received augmentation rhinoplasty surgery over the past 4 years with an average postoperative follow-up of 12 months. Among these patients, 78 of them were primary cases and others were secondary or more. The cartilaginous framework was reconstructed based on comma strut with other grafts including spreaders and dorsal onlay grafts.

RESULTS

Patients' own evaluations on the overall improvements of the nose rendered high satisfaction rate. During the long-term follow-up, 8 cases presented asymmetrical nostrils with slightly deviated columella; minor revision surgeries were performed. Another 3 cases presented dorsal graft warping and were also corrected. No other major complications were encountered.

CONCLUSIONS

The comma strut provides a reliable support for the nasal tip; its dual curved structure plays the instrumental role in defining the lobular-columellar angle as well as modifying the supratip break. This graft design offers good control of tip and columella; as a result, consistent, reproducible results can be achieved.

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 .

Economizing the Septal Cartilage for Grafts During Rhinoplasty, 40 Years' Experience

BACKGROUND

During rhinoplasty, it is typically necessary to use cartilage to shape and support the final nasal construct to provide both form and function to the nose (Tanna et al. in Plast Reconstr Surg 141(1):137e-151e, 2018; Guyuron in Plast Reconstr Surg 105(6):2257-2259, 2000; Kim et al. in Ann Plast Surg 65(6):519-523, 2010). The septal cartilage is the ideal graft both for its ease of access and quality of cartilage. However, this graft is a limited resource, and economy of its use is important as to negate the need to harvest cartilage from the ear or rib.

THE PURPOSE

1. To share the senior author's 40 years' experience with the economy of septal cartilage. 2. To identify the areas of the septal cartilage most suitable for a particular graft. 3. To discuss the common grafts that are used in rhinoplasty. 4. To identify when other sources of cartilage are needed and where to best use those grafts. 5. To present option for preservation of the leftover septal cartilage.

CONCLUSION

Overall consideration should focus on the size, thickness, and curvature of the graft contemplating the structural and functional needs of the rhinoplasty maneuvers.

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 .

Correction of secondary unilateral cleft lip nasal deformity in adults using lower lateral cartilage repositioning, columellar strut, and onlay cartilage graft on the nasal tip with open rhinoplasty combined with reverse-U incision

A rhinoplasty technique involving lower lateral cartilage (LLC) repositioning and grafting of ear cartilage allows for nasal lengthening and nasal tip mobility. For better esthetic outcomes in patients with cleft lip nasal deformity (CLND), we combined cosmetic nasal tip plasty with standard techniques. We performed open rhinoplasty combined with reverse-U incision and V-Y plasty in 62 patients with secondary unilateral CLND from October 2013 to June 2018. Both LLCs were isolated, repositioned, approximated medially, and advanced with a Medpor strut, followed by tip suture technique. To further project and enhance the nasal tip and columella, application of ear cartilage onlay graft was used. As adjunctive procedures, septoplasty or osteotomy was carried out for correction of septal or nasal bone deviations, respectively. Photogrammetric evaluations of patients and statistical analyses were performed. Average age at operation was 23.5 years (range: 18-42 years). Of the 62 patients, 15 underwent dorsal augmentation with silicone implant. Two-layer conchal cartilage onlay grafting was performed to manage tip height. Outcomes in 34 patients were analyzed with pre- and postoperative photography. Nasal tip projection increased, alar base width index decreased, and alar and columellar symmetry significantly improved. No Medpor implant exposure or other adverse outcomes occurred. The proposed technique is effective for correcting secondary unilateral CLND and achieving a satisfying nasal appearance in adults.

Preservation Rhinoplasty for the Dorsum and Tip

By performing a preservation rhinoplasty, the surgeon can achieve natural and stable results by intraoperative replacement of resection with preservation and excision with manipulation of ligaments, cartilages, soft tissues, and the osseocartilaginous dorsum. In this article, the authors explain step by step the dorsal preservation rhinoplasty with low septal strip and a combination of nasal bones osteoplasty and osteotomies, the tip preservation rhinoplasty based on nose tip polygons, and the authors' technique for modify the nasal tip projection and rotation with a posterior strut or anterior septal strip.

A Novel Technique of Asian Tip Plasty: Rein-Shaped Columellar Strut Graft

BACKGROUND

The columellar strut graft is one of the most commonly used invisible grafts in tip plasty techniques for nasal tip projection. However, the columellar strut graft induces cephalic rotation of the dome with nasal tip projection. This is an effective change in Western people with a long nose; however, this change should be avoided in Asians who have a relatively short nose and visible nostrils. We designed a more convenient and effective technique using a rein-shaped columellar strut graft that can prevent cephalic rotation of the dome.

METHODS

A total of 32 patients underwent surgery with a rein-shaped columellar strut graft with a septal cartilage. The projection and location of the nasal tip, nasal length, and nasolabial angle were measured after taking a photograph of the lateral view, and the preoperative and postoperative results were compared.

RESULTS

There were statistically significant differences between the preoperative and postoperative values of the nasal tip projection ratio and nasal tip location ratio. There were no revision surgeries and no direct complications associated with the use of the columellar strut graft.

CONCLUSION

We performed tip plasty with a modified columellar strut graft-the rein-shaped columellar strut graft. In most cases of using this method, the tip projection was increased and the cephalic rotation of the tip was prevented. This surgical procedure can also be used for lengthening (rotating caudally) of the nose in some cases, as well as for the purpose of preventing the cephalic rotation of the tip.

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 hump columellar strut: a reliable technique for correction of nasal tip underprojection

Nasal tip under projection is often found in rhinoplasty cases both for congenital or post-traumatic deformity. Nasal trauma may result in alteration of the external and internal nasal structures with following aesthetic impairment and difficulties in breathing. Post-traumatic surgery is frequent, but restoration of pre-traumatic form and function remains a challenge. The present paper describes a new method to increase tip projection by a columellar strut harvested from the autologous nasal bone and cartilage of the resected hump. A total of 15 cases (11 women/4 men, mean age 32.6 ± 12.3 years) of major tip projection/misalignment abnormalities to be corrected by increased nasal tip projection were drawn, and all underwent closed or open rhinoplasty with the placement of a bony columellar strut harvested from the resected hump of the patient. Short and long-term advantages of this procedure are to be underlined. Harvesting is routinely performed during dorsal resection and preparation of the graft is easy. Differently from bone of the vomer or the inferior turbinate, this is cortical bone straight in shape and rigid in framework, and therefore ideal to gain reliable tip support overtime. No additional harvesting areas are needed. Placement of this bony strut is carried out in the standard fashion without additional dissection or further procedures. Long-term follow-up shows maintained projection over time. This graft can be combined with various grafting or suturing techniques usually applied according to each surgeon's experience and the needs of each patient.

Reconstruction of nasal tip support in primary, open approach septorhinoplasty : A retrospective analysis between the tongue-in-groove technique and the columellar strut

The reconstruction of the nasal tip support is one of the most essential issues in septorhinoplasty. A comparison of the results after using the tongue-in-groove technique and the columellar strut technique was the target of this study. Thirty-three patients who underwent a primary, open approach septorhinoplasty using the above-mentioned techniques were retrospectively analyzed. The gain in tip rotation postoperatively, the sensitivity and the rigidity of the nasal tip and the aesthetic outcome after surgery were examined and evaluated. Both techniques led to an increase in nasal tip rotation postoperatively. The gain in rotation was higher in patients, treated with the tongue-in-groove technique (p = 0.0052). The sensitivity of the tip region in the tongue-in-groove group of patients was significantly lower than that in the columellar strut group of patients (p = 0.0424). Both techniques led to high percentages of tip rigidity after surgery with satisfactory aesthetic results though. The tongue-in-groove technique and the columellar strut technique are both reliable techniques for reconstructing the nasal tip support and correcting a droopy tip. Although the tongue-in-groove technique might result in a more significant increase in tip rotation, it leads to less sensitivity in the tip region.

Contemporary techniques for effective nasal lengthening

The short nose deformity is a complex entity with diverse causes and variable characteristics. This article divides shortening into anterior and pan-nose shortening as well as mild, moderate, or severe. Mild anterior shortening can be corrected with shield grafting, whereas moderate to severe shortening can be corrected using septal extension grafts, composite grafts, or the tongue-and-groove technique. Ancillary technical considerations are reviewed. General principles of patient assessment and rhinoplasty execution are discussed. Surgical cases are presented, and pertinent aspects of preoperative planning, surgical technique, and perioperative care are discussed.