Vertical Alar Lengthening technique in correcting short noses

BACKGROUND

It is crucial that the nose length must be compatible with the face in order to obtain beautiful results that suits the face. Shorter and upturned noses appear as if the tip of the nose is cut from the front and gives a piggy appearance to the patient's face.

OBJECTIVE

The aim of this study is to obtain longer noses with increased tip definition by effectively lengthening the medial and lateral crura's in patients with short nose and Asian noses.

MATERIALS AND METHODS

Vertical Alar Lengthening (VAL) technique was applied to 17 revision and 12 primary Asian noses. VAL technique consists of three steps. In the first step, the medial crus were lengthened by stealing from the lateral crus. Later, a lateral crural extension graft was applied to the shortened lateral crus, and the lateral crus was lengthened and sutured to the medial crus. In the final stage, a subdomal graft was placed and supported in the space formed underneath the alar tip between the mucosa and the new dome. They were followed in average 12 months (between 6 and 18 months).

RESULTS

VAL technique was applied to 17 revision and 12 primer Asian noses. Suggested surgical technique move the tip forward and downward reduced its cephalic rotation and lengthened the nose. Targeted tip point, rotation and projection results were achieved in all patients. All patients had satisfactory esthetic results.

CONCLUSIONS

In revision cases and short nose deformities in Asian noses, the nasal tip point was extended forward and downward with the VAL technique, reducing its rotation and lengthening the nose.

Correction of Short Nose Using M-shaped Cartilage in Asian Patients: Finite Element Analysis and Recommendations for Surgery

BACKGROUND

Using M-shaped cartilage grafts is a new method for the correction of short nose deformity with good effect for Asians. Although the basic approach to M-shaped cartilage surgery is well understood, there is a great deal of uncertainty when plastic surgeons perform the procedure, and still a lack of standard guidance on the specific details.

METHODS

In this study, the authors used finite element analysis to explore and compare postoperative cartilage stability of different fixing methods, different suturing positions, and different sizes of M-shaped cartilage. The authors applied a 0.01 N load to a 1 cm2 area of the nasal tip to simulate nasal tip palpation and compared the maximum deformations of different groups, which were used to make stability judgments.

RESULTS

The maximum deformation of the model was the least when the M-shaped cartilage was fixed medially to the septal cartilage and laterally to the outer crura of the lower lateral cartilage. At the same time, the maximum deformation was the least when the M-shaped cartilage was sutured to the middle of the nasal septal cartilage. Besides, the length of M-shaped cartilage was preferably around 30 mm, while its width was not worthy of being overly concerned.

CONCLUSIONS

For optimal postoperative stability of Asian short nose correction, the M-shaped cartilage should be sutured and fixed medially to the middle of the septal cartilage and laterally to the lateral crura of the lower lateral cartilage, and the length of the M-shaped cartilage should be controlled at around 30 mm.

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 .

M-Shaped Auricular Cartilage Grafts for Correcting Short Nose Deformity in Asians: A Retrospective Study

BACKGROUND

The demand for rhinoplasty in Asia is growing annually, and short nose deformity has been one of the main reasons for the surgery due to its high incidence. There is an urgent need for rhinoplasty suitable for Asians because of their different facial features from Westerners. The M-shaped auricular cartilage rhinoplasty has been developed as a new method for correcting short nose deformity for Asians. This study aimed to evaluate the aesthetic and functional results of M-shaped auricular cartilage rhinoplasty compared to clinically commonly used rhinoplasty methods.

METHODS

A total of 45 patients were enrolled and divided into three groups of 15 patients: The first group underwent M-shaped auricular cartilage rhinoplasty, the second group underwent auricular-septal cartilage rhinoplasty, and the third group underwent overlapped auricular cartilage rhinoplasty. All of these patients underwent comprehensive rhinoplasty and had silicone or expanded polytetrafluoroethylene implants in the dorsum of their noses.

RESULTS

The patient score improvements on the three patient-reported outcome measures were higher in the M-shaped auricular cartilage rhinoplasty group (1.65/1.79/0.11) compared with the overlapped auricular cartilage rhinoplasty group (1.40/1.51/0.05), and the score improvements in the auricular-septal cartilage rhinoplasty group (2.04/1.98/0.28) were the highest.

CONCLUSIONS

This is a retrospective clinical study demonstrating the clinical efficacy of M-shaped auricular cartilage rhinoplasty. Compared with the overlapped auricular cartilage rhinoplasty, the effect of this novel M-shaped method is better. However, when compared to the auricular-septal cartilage rhinoplasty with septal extension and reinforcement using nasal septal cartilage, its effect is slightly worse.

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 .

"Nasal lining rotation flap with triangular fossa composite graft, an effective method for managing the multiply-revised Asian short nose"

BACKGROUND AND OBJECTIVES

Postoperative short nose is one of the most difficult problems encountered in plastic surgery. We propose a technique of lining rotation flaps combined with composite chondrocutaneous auricular graft from the triangular fossa to reconstruct the lining defect and improve surgical results.

METHODS

Twenty patients were operated on between 2016 and 2019 for postoperative short nose. Lining rotation flaps were used to supply missing medial mucosal lining with creation of a raw surface at the lateral lining in 10 patients (intervention group). A total of 17 composite chondrocutaneous grafts taken from the triangular fossa of the ears were used to resurface the defect. The other 10 patients received lining management using conventional techniques (control group).

RESULTS

There was a near-complete take of 13/17 composite grafts (76.5%), with four partial losses that healed uneventfully. Anthropometric analysis of preop and postop profile photos showed statistically significant decreased nasolabial angle in both groups. The amount of derotation achieved was significantly increased (p < 0.05) with our proposed method (Intervention group: 12.3 ± 9.3° vs. control group: 6.55 ± 4.5°). Donor sites healed uneventfully. Both groups of patients were satisfied with their results based on Rhinoplasty Outcomes Evaluation questionnaire.

CONCLUSIONS

The lining rotation flap with triangular fossa composite graft is a safe and effective method for management of the postoperative short nose in Asians.

Special Consideration in Rhinoplasty for Deformed Nose of East Asians

Typical Asian deformed nose has many different types: concave nasal dorsum, low nasal dorsum, wide nasal dorsum, deviated nose, convex nasal dorsum, saddle nose, short-nose deformity, and deformities involving irreversible damage of skin/soft tissue envelop are the most representative ones. The key concept in Asian rhinoplasty is augmentation in all different forms of nasal deformities. Augmentation of the nose consists of framework, tip, and dorsal augmentation. Septal extension grafting and tip grafting are 2 maneuvers with profound importance in augmentation of lower two-thirds of the Asian nose. Dorsal augmentation is central concept in beautifying all different types of deformed noses, even the hump nose.

A Comparative Study Between Classic Derotation Graft and Novel Double V Cutting Folded Derotation Graft

BACKGROUND

To introduce an innovative refinement, the "double V cutting folded derotation graft" (DVCFD graft), which is a method for nasal tip lengthening in aesthetic rhinoplasty with strong holding force and efficient cartilage use.

METHODS

A retrospective study was conducted from January 2018 to July 2019 with 101 patients, including 11 males and 90 females with an average age of 36.87 ± 10.12 years, at Chang Gung Memorial Hospital; the patients received classic derotation grafts (n = 49, 17 of them were one layer and 32 of them were two layers) and DVCFD grafts (n = 52) for cosmetic tip plasty. The tip projection, columella labial angle and nasolabial angle were measured through clinical photography at three different times (T0: pre-operation, T1: two weeks post-operation and T2: five months post-operation). The differences between the original derotation graft and the DVCFD graft were identified using paired-t and independent-t tests.

RESULTS

The final relapse ratios of the classic derotation graft and DVCFD graft were 36.78% versus 36.92% for tip projection, 40.65% versus 38.58% for columella labial angle and 45.00% versus 47.76% for nasal labial angle, respectively. The P values of the independent-t tests were 0.991, 0.564 and 0.439, respectively.

CONCLUSIONS

Both the classic derotation graft and DVCFD graft possess similar stability in tip plasty. The novel modification of the DVCFD graft has more efficient cartilage usage and is a feasible and safe surgical option for patients with limited harvestable cartilage for tip lengthening.

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 .

[Secondary rhinoplasties]

As a very challenging surgery, primary rhinoplasty can lead to secondary. After a primary, patient's concerns can sometimes be pretty easy to fix (remaining bump), but may some other request long and very difficult surgeries (short nose). This article describes the most common reasons of secondary rhinoplasties and provides, for each of them, a surgical treatment.

Nasal Elongation with Septal Half Extension Graft: Modification of Conventional Septal Extension Graft Using Minimal Septal Cartilage

BACKGROUND

In Asian rhinoplasty, a septal extension graft can be used for both tip projection and derotation of the alar cartilage. However, patients often do not have enough harvestable septal cartilage to create the septal extension graft. We therefore devised a method with which to fix the derotated alar cartilage with a small amount of septal cartilage.

METHODS

From January 2012 to December 2016, 23 patients underwent short nose correction with a septal half extension graft made of septal cartilage and were postoperatively monitored for at least 6 months. The alar cartilage was completely separated from the adjacent structures, especially the scroll area and hinge complex, for caudal derotation. The septal half extension graft was then harvested from the septal cartilage and secured to the caudal septum and the lateral crura of the alar cartilage. Photographs of the patients were compared immediately before surgery and 1 year after surgery.

RESULTS

Of the 23 patients, 21 (91%) had satisfactory results without short nose recurrence. Two (9%) patients developed recurrence: undercorrection and poor tip projection in one patient each. Aesthetic assessment of short nose correction was performed by comparing the columellar labial angle before and after surgery. Our method reduced the columellar labial angle by 6.2% (paired t test, p < 0.05, t = 31.698).

CONCLUSION

In patients who cannot undergo conventional septal extension graft due to insufficient amounts of septal cartilage, the septal half extension graft could be a promising alternative technique for short nose correction with minimal septal cartilage harvesting.

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 .

Correction of Short Nose

To correct an Asian short nose with low dorsum, short columella, and poorly defined nose tip, augmentation rhinoplasty has been popularized. A simple augmentation no longer is considered an efficient rhinoplasty approach for Asians aesthetically; most surgeons simultaneously perform nasal elongation and augmentation during rhinoplasty. To extend the nose length successfully, important factors are cartilages, mucosal and skin conditions, and presence and degree of fibrotic changes. In addition, surgeons should consider preoperatively how much should be extended from an aesthetics perspective. This article introduces the current practice of surgical correction of the short nose in Asians.

Septal Cartilage/Ethmoid Bone Composite Graft: A New and Improved Method for the Correction Underdeveloped Nasal Septum in Patients with Short Noses

BACKGROUND

Septal extension grafts are an effective means of extending nasal length in patients with a short nose. However, such grafts can be challenging in patients who only have small quantities of weak septal cartilage, such as some East Asian patients. We developed a rhinoplasty technique using ethmoid bone to create a cartilage-bone complex to overcome this issue, allowing adequate nasal lengthening.

METHODS

Sixty-four women with short noses and inadequate septal cartilage determined by preoperative computed tomography underwent septal extension grafting with a cartilage-bone complex between January 2009 and December 2014. Septal cartilage and ethmoid bone were harvested during open rhinoplasty and secured to the septal cartilage.

RESULTS

Most patients were in their twenties or thirties. All patients underwent septal extension grafting using a cartilage-bone complex and dorsal augmentation with silicone implants. Short nasal length, decreased nasolabial angle and increased nostril show, were rectified. There was no recurrence during a mean follow-up period of 12.3 months, although one patient (1.5%) requested revision surgery.

CONCLUSION

Septal extension grafting with a cartilage-bone complex can be used to correct a short nose, especially in Asians who have relatively small amounts of septal cartilage. The ethmoid bone augments the inadequate septum and provides structural support.

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 severe columella and tip retraction in silicone implanted Asian short noses

Background

Silicone Implants and other alloplastic materials are frequently used in rhinoplasty to augment Asian short noses. However, nasal deformities as a result of implant-related infections are increasing in incidence. The resulting tissue scarrings hinder the application of traditional techniques of lengthening short noses. The following paper presents a technique to correct severe postoperative retractions of the tip and columella caused by silicone implants.

Methods

We present a retrospective case study of two Asian patients with recurrent acute infections, secondary to silicone dorsum implants, leading to chronic inflammation of the tip and columella. The treatment consisted of implant removal and the immediate nasal reconstruction by combining uni- or bilateral gingivobuccal flaps along with L-shaped costal cartilage grafting.

To evaluate the surgical results, various anthropometric measurements, particularly the nasal length (NL) and nasal tip projection (NTP) of pre- and postoperative profile photographs, were analyzed.

Results

Successful nasal lengthening and correction of columellar retraction were achieved. In case I, postoperative NTP and NL increased by 34.7 % and 21.1 %, respectively. In case II, NL and NTP increased by 23.8 % and 10.6 %, respectively. However, case II presented necrosis of the distal extremity of one gingivobuccal flap without rib graft resorption, which later healed by secondary intention.

Conclusion

Pronounced columellar retraction in severe short noses can be successfully managed with a combination of gingivobuccal flaps along with L-shaped costal cartilage grafting. The use of autologous materials decreases the risk of long-term extrusion through the tip. The gingivobuccal flap provides vascularity to the exposed rib cartilage on the columella and prevents its resorption.

The Short Nose

The causes of the short nose deformity vary greatly, from congenital malformations to acquired deformities. Despite this degree of variation, key commonalities exist, namely, a shortened nasal length, overrotation of the nasal tip, and increased nostril show. This article is designed to help the reader identify precise causes of the short nose, outline associated anatomy, and discuss reliable surgical techniques to correct this deformity.

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.

[Secondary rhinoplasty]

Secondary rhinoplasty is very usual. Some patients are not satisfied by the previous surgery because the result is poor with obvious defaults but, sometimes, the result is good but the patient expects perfection. These two different situations will not lead to the same answer from the surgeon. Techniques of secondary rhinoplasty are the same than primary, but are often more difficult to perform because of scar tissue, retraction and loss of lining. The authors analyse the more frequent deformities in secondary rhinoplasty and the way they fix them.

[The short nose]

Short noses are not only depending on the length of the dorsum, but also if there is a saddle deformity, or a too lower situation of the fronto-nasal angle, or an open naso-labial angle or a rim retraction. All the cases are treated, often with the help of cartilage grafts and with a closed approach.

Rhinoplasty in the Asian nose

For Asian people with poorly developed dorsal height and tip height combined with thick skin, augmentation is the most common procedure in rhinoplasty. Nasal deformities are also prevalent. Frequent use of dorsal augmentation material and grafting procedures in Asian rhinoplasty results in a relatively high rate of revision surgery to correct complications. This article describes dorsal augmentation using alloplastic implant materials and several tip grafting procedures. Surgical techniques for the correction of a deviated nose and convex dorsum are also discussed, with emphasis on extracorporeal septoplasty as modified by the senior author. A technical guide is described to treat this condition.

Surgical correction of "rhinoplastic look"

A pointed, narrow and exaggeratedly upturned nasal tip and concave dorsal profile can give the nose an unnatural and artificial appearance that is the unmistakable hallmark of plastic surgery. As a result of changes in social attitudes, noses that have evidently been operated on are no longer acceptable and requests are made for correction. While a more natural dorsal profile can be obtained with camouflage grafts of autologous cartilage or alloplastic material (EPTFE), autologous grafts alone are used to reconstruct the tip. The most complex correction regards an obtuse nasolabial angle, for which the extension graft technique is used. Particular care must be taken during preoperative planning, where the aid of computer simulation and agreement with the patient are essential.