Alar Rim Deformities in Korean Primary Rhinoplasty Patients

Background and Objectives: The alar-columellar relationship plays an important role in the esthetic balance of the nose. We analyzed alar rim deformities and aesthetic concerns and expectations among patients by deformity type in Korean primary rhinoplasty patients.Materials and Methods: Retrospective photographic analysis was done on 336 patients planning to undergo primary rhinoplasty at Kyung Hee University Hospital at Gangdong. We categorized their alar rim deformities as normal, hanging columella, retracted columella, hanging ala, retracted ala, convex ala, concave ala, thick ala, and a combination of the above. Patients’ aesthetic concerns and expectations about their nose were analyzed by preoperative questionnaire.Results: Of the enrolled patients, 38 (11.3%) had no alar rim deformities, and the other 298 patients (88.7%) had one or more deformities. The most prevalent alar rim deformity was hanging ala (59.2%), followed by convex ala (53.3%) and thick ala (32.1%). Male patients were more likely to have convex ala and retracted columella than female patients. More than one-half of the patients (64.1%) had two or more deformities and tended to be young (p=0.028). Patients with thick ala had several reasons for being dissatisfied with their nose and various demands for correction.Conclusion: Distinctive characteristics of alar rim deformities should be considered in surgical planning in order to obtain satisfactory results in Korean primary rhinoplasty patients.

Inaccuracy of Standard 2D Photography for the Diagnosis of Cephalic Malposition of Lateral Crural Cartilages

Lateral crural cephalic malposition (LCCM) is a well-known deformity of the nasal tip which contributes to functional disturbances of the external nasal valve. Accurate diagnosis of this deformity helps surgeons plan for better outcomes. A total of 176 candidate patients for primary rhinoplasty underwent standard 2D medical photography of the face. Senior authors analyzed photography results and differentiated the patients with LCCM. In addition, we measured the angle between the dorsal septum and lateral end of the long axis of the alar cartilage in the operation room. Ninety-five patients were diagnosed with LCCM on photography. As much as 31.3% (55) of all the patients had LCCM in intraoperative measurements. The sensitivity and specificity of 2D photography for diagnosing LCCM were 0.7924 and 0.5391, respectively. The main surgical techniques for correction of LCCM were alar repositioning (34.3% in total, 56% in LCCM patients) and lateral crural strut graft (43.8% in total, 69% in LCCM patients). LCCM is overdiagnosed via 2D photography, and this method lacks sensitivity. The overall frequency of LCCM seems to be lower than the previously reported frequency. For optimal results in rhinoplasty, surgeons must focus on the best contouring and function rather than solely correcting angles and rotations.

Cost Utility Analysis of Costal Cartilage Autografts and Human Cadaveric Allografts in Rhinoplasty

Background: Human cadaveric allograft (HCA) and costal cartilage autograft (CCA) have been described for reconstruction during rhinoplasty. Neither are ideal due to infection, resorption, and donor site morbidity. The clear superiority of 1 graft over the other has not yet been demonstrated. This study assesses comparative costs associated with current grafting materials to better explore the cost ceiling for a theoretical tissue engineered implant. Materials and methods: A cost utility analysis was performed. Initial procedure costs include physician fees (CPT 30420), hospital outpatient prospective payments, ambulatory surgical center payments, and fees for the following: rib graft (CPT 20910), hospital observation, and DRG (155) for inpatient admission. Additional costs for revision procedure, included the following fees: physician (CPT 30345), rib graft, hospital outpatient prospective payment, and ambulatory surgical center payments. Total costs under each scenario were calculated with and without the revision procedure. Comparison of total costs for each potential outcome to the estimated health utility value allowed for comparison across rhinoplasty subgroups. Results: The mean cost of primary outpatient rhinoplasty using HCA and CCA were $8075 and $8342 respectively. Revision outpatient rhinoplasty averaged $7447 and increased to $8228 if costal cartilage harvest was required. Hospital admission increased the cost of primary rhinoplasty with CCA to $8609 for observational admission and to $13653 for 1 day inpatient admission. Revision CCA rhinoplasty with an inpatient admission complicated by pneumothorax increased costs to $21 099. Conclusion: Cost of rhinoplasty without hospitalization was similar between HCA and CCA and this cost represents the lower limit of a practical cost for an engineered graft. Considering complications such as need for revision or for admission after CCA due to surgical morbidity, the upper limit of cost for an engineered implant would approximately double.

Analysis of the causes of unsuccessful rhinoplasty

Aim. To study results of unsuccessful primary rhinoplasty that require repeated interventions.Material and methods. The work summarizes the analysis of the causes of unsuccessful rhinoplasty in 106 patients who had previously suffered a primary septorhinoplasty in various health facilities in Tajikistan in the period from 1 to 7 years. The main reason for the visit was dissatisfaction with the previous rhinoplasty.Results and discussion. After primary rhinoplasty, patients most often had the following deformities: deformity of the tip of the nose (72 patients); deformity of the “parrot beak” type (14 patients); deformation similar to the inverted “V” (12 patients); deformation of the contours of the nasal dorsum (13 patients); defects of the nasal septum in the lower caudal region (21 patients). All patients underwent secondary rhinoplasty.Conclusion. Unsuccessfully executed as a primary rhinoplasty leads to respiratory dysfunction and aesthetic defects that require more complex secondary surgical operations.

Photometric Evaluation of Adult Patients With Bilateral Cleft Lip and Palate Treated With Nasoalveolar Molding and Primary Columella Lengthening

A short columella and a flattened nasal tip are the characteristic stigmata of patients with complete bilateral cleft lip and palate (BCLP). Objective: The aim of this study was to assess the nasal shape of young adults with BCLP treated with primary surgical columella lengthening and nasoalveolar molding (NAM). Setting and Patients: A group of 28 young adult patients with BCLP (mean age: 19.1±1.4 years) was compared through normalized photogrammetry to a control of 28 age- and sex-matched noncleft young adults. Results: Nasal protrusion and length of the columella were not different from noncleft young adults. On the other hand, nasolabial angle, columellar width, interalar, and nasal tip width were significantly wider than the noncleft controls. Thus, 27% of the patients have requested at this time secondary correction of the excessive nasal width. Conclusions: Both NAM and primary rhinoplasty in patients with BCLP resulted in a near normal length of the columella and nasal projection until young adulthood. Nevertheless, width of all nasal features was significantly wider than the noncleft population and required secondary nasal correction in one-third of the sample.

Assessment of Columellar Widening with Columellar Strut Placement

Objective: The columellar strut is a frequently used technique to provide nasal tip support and projection that is commonly thought to increase columellar width. However, systematic review of the effect has not been reported in the literature. We report a quantitative evaluation of the effect of columellar strut placement on columellar width. Methods: A retrospective cohort study of changes in columellar width in base view photographs for patients who underwent primary rhinoplasty with columellar strut placement (n = 35) and the closely related septal extension graft (n = 9) and tongue-in-groove (n = 5) procedures at Mount Sinai Hospital between 2010 and 2017. The ratio of the columellar width to the intercanthal distance was used to standardize the results among patients. Comparisons were made at follow-up periods of <1 week, 2 to 4 weeks, 1 to 3 months, 3 to 6 months, 6 to 12 months, and >1 year of follow-up. Results: Forty-nine patients (41% female; average age of 43 ± 15 years) were reviewed. The columellar width showed a statistically significant increase for all follow-up date ranges with the exception of 1 week and 3 to 6 months post-operatively. At >1 year of post-operative follow-up, the mean increase in columellar width was 8.6% (95% CI, 2.6%-14.5%, P = .0098). No statistically significant differences were noted between open versus closed procedure for all followup visits after the 1 week followup, and no significant difference if a septocolumellar stitch was placed. Conclusions: A columellar strut was demonstrated to lead to an increase in columellar width. Though the effect was modest at a 8.6% increase, this is a potential cosmetic consideration for the surgeon employing its use to provide nasal tip support and projection.

Revision Rhinoplasty: With Introduction of a Novel Preoperative Assessment Classification System

Revision rhinoplasty presents several complex surgical challenges. Proper patient selection for revision rhinoplasty, along with thorough preoperative examination and surgical planning, is key to achieving ideal outcomes. Along with achieving a high level of understanding of primary rhinoplasty techniques, surgeons performing revision rhinoplasty must understand and diagnose deformities created by the primary surgery. A systematic approach to diagnosing rhinoplasty deformities assists in forming a suitable surgical plan. A classification system based on nasal analysis, described here, may be used to differentiate the degree of difficulty of the surgery as well as assist in surgical planning. Surgeons have a multitude of options available in their armamentarium for addressing common nasal deformities encountered during revisional surgery, and a stepwise surgical approach may facilitate the creation of an optimal aesthetic and functional result.