Improving Projection of the Nasal Tip in Primary Endonasal Rhinoplasty

Gaining, improving, and maintaining nasal tip projection is one of the most essential elements of successful endonasal rhinoplasty. For years the hallmark of inadequate nasal tip projection following rhinoplasty has been the Polly beak deformity. Early rhinoplasty technique consisted of intracartilaginous excision of the cephalic margin of the lower lateral cartilages, cartilage and bony hump reduction, and osteotomies. Some of these simple rhinoplasties still look good decades later, however, many are conspicuous in their lack of nasal tip projection. The reason for this inconsistency in rhinoplasty results was the surgeon's inattention to the structural integrity and anatomical position of the LLC. The senior author uses a combination of suture, strut, and cartilage grafting techniques to achieve ideal projection in a manor tailored to each patient's unique anatomic needs.

Changes to the Cleft Nose Esthetic After Le Fort I Advancement: A 3-Dimensional Analysis

Background and Purpose: The study of nasal changes in cleft lip and palate (CLP) orthognathics is limited. This study aimed to determine differences in 3-dimensional (3D) nasal changes for unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP) patients after Le Fort I advancement. Methods: This study was a retrospective cohort evaluation of 18 subjects (9 male, 9 female) treated at a single institution over a 5-year period who had class III skeletal and dentoalveolar malocclusion related to non-syndromic cleft lip and/or palate and underwent surgical correction via Le Fort I osteotomy. Patients underwent pre- and postoperative cephalometric measurements and 3D volumetric assessment for comparison to analyze nasal changes. Statistical analysis was performed to determine changes in nasal parameters using student’s t-test and multivariate analysis. Differences were considered significant for P-values ≤.05. Results: All nasal parameters except for nasolabial angle and nasal length changed significantly postoperatively in the entire cohort. Alar base and flare width both increased significantly (2.1 mm, P = .0002, 1.4 mm, P = .0005), while both relative and total tip projection decreased (−3.4 mm, P = .000004, −2.2 mm, P = .0008). An advancement of the entire nasal complex was seen postoperatively (1.0 mm, P = .0005). UCLP patients had a significantly larger decrease in total nasal tip projection following surgery relative to BCLP patients (−3.5 ± 1.2 mm, −0.8 ± 2.1 mm, P = .008). BCLP morphology increases the degree of 3D nasal surface area advancement relative to UCLP (1.2 mm ± 0.3, 0.8 mm ± 0.6, P = .028). Alar cinch stitch decreases nasolabial angle ( P = .024) but increases nasal length ( P = .004). Conclusion: Discrepancies exist in nasal changes after Le Fort I advancement between UCLP and BCLP patients. Increased understanding of outcomes for cleft patients undergoing Le Fort I can help improve the predictability of nasal esthetic changes in this patient population.

Three-Dimensional Analysis of Definitive Secondary Unilateral Cleft Rhinoplasty Using Cartilage Graft

Objective Three-dimensional assessment of nasal morphology in patients with unilateral cleft lip nose treated by cartilage graft augmentation. Design Retrospective study. Patients and Intervention Thirteen patients with unilateral cleft lip nose underwent definitive secondary rhinoplasty and postsurgical changes were examined using a three-dimensional (3D) laser scan. Main Outcome Measure Nasal dorsum length, nasal tip, alar width, and alar base width in frontal view; nasion depth, nasal tip projection, nasal dorsal angle, and nasal tip angle in lateral view; nostril width, nostril height, and nasal tip height in basal view were measured at preoperative (T1: within 6 months), short follow-up (T2: 2-10 weeks), and long follow-up (T3: 9-14 months). Results A significant change in alar width, alar base width, nostril width, and nostril height at the cleft side, nasal dorsum length, nasion depth, nasal tip projection, and nasal tip height was observed from T1 to T3 follow-up after rhinoplasty ( P < .05), whereas the nostril height at the noncleft side was also significantly increased at T2 follow-up but the mean change in height relapsed at T3 follow-up. Alar width, alar base width, and nostril width at the noncleft side, and nasal tip angle did not change significantly after surgery at any follow-up period. Conclusions 3D imaging evaluation after secondary cleft rhinoplasty demonstrated improved functional and aesthetic outcomes using a septal or conchal graft.

Polycaprolactone Mesh for Asian Rhinoplasty: Outcomes and Complications of Composite Septal Extension Graft Compared to Mesh-Only Graft

Despite the great demand of aesthetic rhinoplasty in Asian population, it is difficult to obtain the lasting ideal tip projection along with lengthening of the nose due to the small and weak nasal septum. The shortage of available septal cartilage to work with is another major obstacle. A retrospective study was conducted between January 2017 and December 2019 in Seoul, Korea. A total of 774 patients underwent septorhinoplasty using polycaprolactone (PCL) mesh for the cosmetic enhancement of the nasal tip and the projection. Comparisons of aesthetic outcomes, patients' satisfaction surveys, and complications were performed between PCL mesh-only group and composite PCL group. Of all the patients, 97.5% of the patients in composite PCL group were rated more than 3 scores in aesthetic outcomes, whereas 90.4% in mesh-only group (p-value = 0.0002). About 96.7% of the patients with composite PCL rated their satisfaction level as more than satisfied, whereas 94.3% in mesh-only group (p-value = 0.0365). Overall, there were 17 patients in composite PCL group who exhibited complications including decreased tip projection, deviated nasal tip, mesh infection, and mesh exposure. However, there were two patients who had mesh injection in mesh-only group. Septorhinoplasty with septal extension graft using composite PCL graft provides robust support to the aesthetically modified projection and the lengthened nose without obvious complications on the nasal tip. Such technique allows surgeons to overcome the nature of Asian nose that is weak and small, and also provides satisfaction to patients who desire ideal tip projections and dramatic changes.

Effectiveness of modified cutting and suture technique for endonasal caudal septoplasty in correcting nasal obstruction and preventing nasal tip projection loss

Purpose Caudal septoplasty is a difficult procedure. The cutting and suture technique is suitable for caudal septoplasty, but a batten graft is always necessary and bears the risk of nasal tip projection loss. We established a modified cutting and suture technique (MCAST), without using a batten graft, and investigated its effectiveness in correcting nasal obstruction and preventing nasal tip projection loss. Methods We retrospectively reviewed the medical records of 22 patients who underwent caudal septoplasty using MCAST. Subjective assessment by Nasal Obstruction Symptom Evaluation (NOSE) score and objective assessment by computed tomography (CT) were performed before and after the surgery. For evaluating nasal tip projection, we asked patients about their awareness of external nasal deformity. Additionally, the nasal tip projection was measured by CT and compared before and after surgery. Results The median preoperative NOSE score reduced significantly after MCAST (P < 0.001). On CT, the ratio of the area of the convex side to that of the concave side in the anterior portion of the nasal cavity increased significantly after MCAST (P < 0.001). All patients were unaware of external nasal deformity. There were no significant differences in the mean preoperative and postoperative nasal tip height and nasolabial angle. The mean supra tip height was significantly greater postoperatively than preoperatively (P = 0.02). Conclusions The MCAST was useful for correcting nasal obstruction with caudal septal deviation. There was no postoperative loss of nasal tip projection. The MCAST can be suitable for correcting C-shaped caudal deviations without dislocating the caudal septum from the anterior nasal septum.

The Caudal Septum Pivot Technique for Short Nose Correction

The short nose represents one of the greatest challenges in rhinoplasty. It is characterized by a reduced distance from the nasal radix to the tip-defining points, often associated with inadequate tip projection. Several techniques have been described for correction of short nose with the common objective of replacing and rebuilding the osteocartilaginous framework. One of the most effective method to correct the short nose is the septal extension graft. The authors describe the caudal septum pivot (CSP) technique, a simple method to elongate short noses by using a graft inserted in the dorsal septum after its division using as pivot the caudal portion, without detaching it from its natural anchorage to the anterior nasal spine. A retrospective analysis was performed reviewing the clinical charts and the operative records of 315 patients who underwent revision rhinoplasty from January 2015 to June 2019; among this group, 34 were considered eligible for the study. The patients (8 men, 26 women; mean age: 25.4 years; age range: 22–53 years) were divided into two groups: in 12 patients (Group 1) the CSP technique was performed, while Group 2 was composed of 22 patients who received a more classic treatment with a septal extension graft. To evaluate the outcomes, nasal length, tip projection, and tip rotation were measured pre- and 1 year postoperatively on digital photographs of each patient. Nasal anthropometric measurements revealed, at 12-month visit follow-up, an improvement in nasal length, tip projection, and nasolabial angle was achieved in all the patients. The comparison of the pre- and postoperative values showed a statistically significant reduction in the nasolabial angle (p < 0.05) and an increase in the tip projection (p < 0.05) and in the nasal lengthening (p < 0.05) in both groups. In authors' experience, the CSP technique could be considered a safe, reliable, and effective alternative technique in selected patients.