Abstract
Background
In 1971, Janeke and Wright1 published a now classic study on the support of the nasal tip in which they found four areas of anatomic support. These findings led to the "tripod ...concept" of tip support. Recently, surgeons have begun repairing and/or preserving the nasal ligaments as a method to control tip projection and rotation. Therefore, a reassessment of the nasal ligaments and tip support is warranted.
Objectives
The present study was done to investigate the ligamentous and structural support of the nasal tip. Clinically, surgeons are aware of the role of the nasal ligaments and are beginning to utilize tip suture techniques to achieve greater tip refinement and long-term support.
Methods
Anatomic studies were conducted on 24 fresh cadavers at the time of autopsy. The two groups consisted of the following: (1) group 1 included dissection of 10 cadavers concentrated on the various ligaments of the nose; and (2) group 2 involved dissections of 14 cadavers analyzing the relationship between the alar domes and the anterior septal angle (ASA).
Results
Regarding the ligaments of the nose, we were able to consistently identify the following ligaments: (1) interdomal; (2) intercrural; (3) Pitanguy's midline; (4) pyriform; and (5) a scroll ligament complex consisting of the longitudinal and vertical scroll ligaments. We did not find two commonly accepted ligaments: (1) a "footplate ligament" from the footplate of the medial crus to the caudal septum; and (2) a "sesamoid ligament" attachment from the accessory cartilage to the pyriform aperture. Dissections done to study the relationship between the domes and ASA revealed that the domes projected an average of 5.7 mm (range, 2.2-9.6 mm) above the ASA and were longitudinally 5.5 mm (range, 2.9-9.5 mm) caudal to the ASA. Thus, there was no direct support from the ASA to the domes.
Conclusions
It is our recommendation that surgeons should consider preservation of the nasal ligaments whenever possible and utilize them to manipulate tip projection, position, and rotation. Awareness of the relationship between the dome and the caudal septum will hopefully minimize problems with the tongue-in-groove operation.
Abstract
Management of the nasal dorsum remains a challenge in rhinoplasty surgery. Currently, the majority of reduction rhinoplasties results in destruction of the keystone area (K-area), which ...requires reconstruction with either spreader grafts or spreader flaps, both for aesthetic and functional reasons. This article will present the senior author's current operative technique for dorsal preservation in reduction rhinoplasty based on 320 clinical cases performed over a 5-year period. The author's operative technique is as follows: (1) endonasal approach; (2) removal of a septal strip in the subdorsal area whose shape and height were determined preoperatively; (3) complete lateral, transverse, and radix osteotomies; and (4) dorsal reduction utilizing either a push down operation (PDO) or a let down operation (LDO). The PDO consists of downward impaction of the fully mobilized nasal pyramid and is utilized in patients with smaller humps (<4 mm). The LDO consists of a maxillary wedge resection and is performed in patients who need more than 4 mm of lowering. A total of 320 patients had a dorsal preservation operation (DPO). Postoperatively, there were no dorsal irregularities nor inverted-V deformities. Among our 44 personal revision cases, 27 patients (8.74%) had had a previous DPO, 16 of whom required tip revisions with no further dorsal surgery. Of the remaining 11 patients, the main problems were either hump recurrence and/or lateral deviation of the dorsum or widening of the middle third, which required simple surgical revision. Based on the authors' experience, adoption of a PDO/LDO is justified in selected primary patients. The key question before any primary rhinoplasty procedure should be "Can I keep the nasal dorsum intact?" Precise analysis and surgical execution are required to preserve the dorsal osseocartilaginous vault and K-area. Dorsal preservation results in more natural postoperative dorsum lines and a "not operated" aspect without the need for midvault reconstruction. Moreover, this technique is quick and easy to perform by any rhinoplasty surgeon. Rhinoplasty surgeons should consider incorporating dorsal preservation techniques in their surgical armamentarium rather than relying solely on the Joseph reduction method or an open structure rhinoplasty.
Level of Evidence: 4
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.
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.
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.
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.
The author has used diced cartilage grafts in nasal surgery for more than 30 years. However, the number of cases and the variety of techniques have increased dramatically over the past 6 years.
The ...author uses three methods of diced cartilage in rhinoplasty surgery: diced cartilage, diced cartilage wrapped in fascia (with fascia then sewn closed), and diced cartilage covered with fascia (with the recipient area covered with fascia after graft placement). The constructs are highly varied to fit the specific defect. Pieces of diced cartilage without any fascia can be placed in pockets in the peripyriform area, radix, or alongside structural rib grafts.
Over a 2-year period, the author treated 546 rhinoplasty cases in which 79 patients (14 percent) had a total of 91 diced cartilage grafts. There were 34 primary and 45 secondary operations involving the radix (n = 11), half-length grafts (n = 14), full-length dorsum (n = 43), peripyriform (n = 16), infralobule (n = 4), and lateral wall (n = 3). All charts were reviewed for the 256 rhinoplasties performed in 2006 of which 30 patients had 35 diced cartilage grafts. With a median follow-up of 19 months (range, 13 to 25 months), two patients had had revisions unrelated to their diced cartilage grafts. The three most common technical problems were overcorrection, visibility, and junctional step-offs.
Diced cartilage grafts are a valuable addition to rhinoplasty surgery. They are highly flexible and useful throughout the nose. Their use simplifies one of the greatest challenges in all of rhinoplasty--dorsal augmentation. Complications have been relatively minor and their correction relatively simple.
Abstract
Background
Preservation rhinoplasty (PR) is a new chapter in rhinoplasty history. The term was coined by Daniel in 2018 and represents a fundamental change in philosophy.
Objectives
The aim ...of this study is to discuss a single-surgeon case series utilizing PR techniques.
Methods
One hundred fifty-three primary rhinoplasty cases were studied retrospectively between December 2016 and August 2017. One hundred cases had at least 1 year of follow-up. Technical details were recorded, including dissection plane, ligament preservation, tip support, lateral crural maneuvers, alar contour grafts, and preservation of the dorsum vs traditional reduction. These 100 cases can be categorized as either complete preservation rhinoplasty (PR-C) or partial preservation rhinoplasty (PR-P).
Results
All patients had open rhinoplasty and the average follow-up time was 13 months. All patients had preservation of the dorsal soft tissue envelope, and in 36 the entire soft tissue envelope and ligaments were preserved. Fifty-four had preservation of the alar cartilages. Thirty-one had dorsal preservation. The combinations include: PR-C (skin, dorsum, and alars): 24; PR-P (skin and dorsum): 2; PR-P (alars and dorsum): 2; and PR-P (skin and alars): 7.
Conclusions
In most patients, the dorsal soft tissue envelope and nasal ligaments can be preserved. When possible, the lateral crura should be preserved and tensioning chosen over excision. Dorsal preservation is a versatile technique when proper patient selection is undertaken, and long-term issues with the middle vault and keystone area can be avoided. Some patients will benefit from total preservation where nothing is removed/disrupted and underlying structures are reshaped.
Level of Evidence: 4
Background
In rhinoplasty surgery, management of the bony vault and lateral walls is most often performed with mechanical instruments: saws, chisels, osteotomes, and rasps. Over the years, these ...instruments have been refined to minimize damage to the surrounding soft tissues and to maximize precision.
Objectives
This article will present the evolution of the authors’ current operative technique based on 185 clinical cases performed over an 19-month period using piezoelectric instrumentation (PEI).
Methods
A two-part study of cadaver dissections and clinical cases was performed using PEI. Evolution of the authors’ clinical technique and the operative sequence were recorded.
Results
Thirty cadaver dissections and 185 clinical cases were performed using PEI, including 82 primary and 103 secondary cases. An extended subperiosteal dissection was developed to visualize all aspects of the open rhinoplasty including the osteotomies. Ultrasonic rhinosculpture (URS) was utilized in 95 patients to shape the bony vault without osteotomies. To date, 11 revisions (6%) have been performed. There were no cases of bone asymmetry, irregularity, or excessive narrowing requiring a revision.
Conclusions
Based on the authors' experience, adoption of PEI is justified and offers more precise analysis and surgical execution with superior results in altering the osseocartilaginous vault. With extensive exposure, surgeons can make an accurate diagnosis of bony deformity and safely contour the bones to achieve narrowing and symmetry of the bony dorsum. Stable osteotomies can be performed under direct vision with precise mobilization and control. As a result of PEI, the upper third of the rhinoplasty operation is no longer shrouded in mystery.
Level of Evidence: 4
Therapeutic
Background
The dorsal hump and dorsal aesthetic lines have been considered bony and cartilaginous structures. Knowledge of the anatomy of the osseocartilaginous vault is essential for obtaining ...aesthetically pleasing results of rhinoplasty.
Objectives
The authors described the morphology, embryology, and clinical relevance of the nasal vault and the changes that occur in this area during rhinoplasty.
Methods
Dissections were performed on 15 fresh adult cadavers to examine the anatomy of the osseocartilaginous vault. Intraoperative endoscopic examination of the vault also was performed in 9 rhinoplasty patients before and after dorsal hump reduction.
Results
In the cadaver study, the average length of the dorsal keystone area, measured along the dorsal septum, was 8.9 mm, and the average width was 4.9 mm. No significant difference in length was observed between cadaver subgroups with straight or humped nasal profiles. The extent of lateral overlap of the nasal bones with the cephalic portion of the upper lateral cartilages varied. In rhinoplasty patients, the average length of the cartilaginous vault exposed during dorsal reduction was 7.6 mm.
Conclusions
The aesthetic lines and profile of the nose before dorsal reduction are dictated by the cartilaginous vault. After reduction, the dorsal lines are determined by the bony vault edges. In routine rhinoplasty, reduction of dorsal height generally corresponds to removal of the dorsal cartilaginous septum.
Composite Dorsal Augmentation Zholtikov, Vitaly; Ouerghi, Riadh; Daniel, Rollin K
Aesthetic surgery journal,
08/2022, Letnik:
42, Številka:
8
Journal Article
Recenzirano
Odprti dostop
Abstract
Background
Dorsal augmentation is one of the most challenging procedures in rhinoplasty. Solid grafts and diced fascia graft (DC-F) have been employed for this purpose with varying success. ...Warping, irregularities, and variability of final height are some of the potential pitfalls.
Objectives
The aim of this study was to assess the efficiency of the authors’ approach combining multiple grafts for nasal dorsal augmentation. They described a technique employing composite dorsal augmentation that is a combination of a foundation layer utilizing high spreader grafts plus a dorsal gap graft combined with a contour layer of 3 possible types of fascia or DC-F grafts. The combination of the 2 layers for the nasal dorsum can be varied to achieve the required height to correct the patient’s deformity and achieve the desired aesthetic goals.
Methods
Fifty-one patients who underwent dorsal augmentation with composite technique between 2017 and 2020 were retrospectively reviewed. A step-by-step algorithm was applied to achieve the required dorsal height.
Results
The patients were divided into 3 groups according to the type of contour graft: double-layer fascia graft, segmental DC-F, or narrow thin full-length DC-F. Smooth continuity and increased projection of the nasal dorsum were achieved in all patients.
Conclusions
Composite dorsal augmentation is an effective technique for dorsal augmentations requiring 4 mm or more of height increase. This technique allows to achieve dorsal augmentation employing a combination of grafts from a single donor site together with camouflaging dorsal irregularities and highlighting dorsal aesthetic lines. This algorithm allows optimization of patients’ aesthetic profile.
Level of Evidence: 4
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