The Utility of the Subalar Graft in Nostril Symmetry in Rhinoplasty.

BACKGROUND: A deviated nose can be attributable to multiple anatomical factors, including asymmetric maxilla. A subalar graft helps to correct maxillary hypoplasia and may be a useful tool for correcting a deviated nose. The authors' objective is to show the effects of the subalar graft in improving nostril symmetry and to propose an algorithm for using this graft in open and endonasal rhinoplasty. METHODS: A retrospective case series was performed on patients who had undergone rhinoplasty performed by the senior author (R.W.) from September of 2008 to July of 2015. Patients with at least 3 months of follow-up and adequate photographs were included. The mean follow-up period was 11.0 months (range, 3 to 72 months). A total of 68 patients were included. Preoperative and postoperative photographs were analyzed to measure changes in nasal axis deviation, alar facial angle on base view, alar facial angle on frontal view, and nostril show bilaterally. RESULTS: Of the 68 patients, statistically significant improvement of nasal axis deviation of 4.32 degrees toward the midline was observed. Alar facial angle on base view was improved 1.01 degrees toward the horizontal. Nostril symmetry also improved based on the ratio between the shorter side and the longer side. The mean change in nostril show ratio was 0.19 toward a 1:1 ratio. CONCLUSIONS: Previous studies have shown that the subalar grafting technique is an important adjunctive technique in rhinoplasty for patients with midfacial asymmetries. This case series demonstrates that this technique can provide sustained results in the correction of the nasal foundation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Effect of depressor septi resection in rhinoplasty on upper lip length.

IMPORTANCE: Resection of the depressor septi in rhinoplasty has been used to correct the smiling deformity. Studying the effects of this maneuver on the upper lip length is important for operative planning, as well as for patient counseling. OBJECTIVE: To define an approach to the resection of the depressor septi muscle during functional and aesthetic rhinoplasty and to determine whether performing this maneuver causes any measureable change in the length of the upper lip in the repose position. DESIGN, SETTING, AND PARTICIPANTS: A retrospective medical record review and photographic analysis were performed on 36 patients who had undergone rhinoplasty involving resection of the depressor septi by either of 2 of the investigators at a tertiary care academic center and a private practice between 2010 and 2013. All maneuvers performed during the procedure were recorded. Preoperative photographs were compared with postoperative photographs using Adobe Photoshop, and percent change in upper lip length was calculated. INTERVENTION: Rhinoplasty involving resection of the depressor septi. MAIN OUTCOME AND MEASURE: Percent change in upper lip length, calculated by measuring the ratio between upper lip length and intercanthal distance and comparing the preoperative and postoperative ratios. RESULTS: Thirty-six patients were evaluated, including 22 men and 14 women. Postoperative photographs were taken a mean (range) of 7.06 months (7 days to 2 years) after surgery. The mean change was a 1.74% decrease in upper lip length; 24 patients (67%) had a decrease (mean [maximum], 5.89% [21.22%]), and 12 patients (33%), an increase (mean [maximum], 6.55% [12.68%]) in upper lip length. Compared with the preoperative lip length, the mean (95% CI) postoperative lip length was 100.09% (97.35%-102.83%) in women vs 95.37% (90.86%-99.88%) in men (P = .07). No predictable factors determined whether a patient would develop a postoperative increase or decrease in upper lip length. CONCLUSIONS AND RELEVANCE: Resection of the depressor septi muscle during rhinoplasty is a well-documented maneuver often used in the treatment of the ptotic tip and smile deformity. This descriptive study showed that resection of the depressor septi muscle has an unpredictable but small effect on upper lip length in the repose position. LEVEL OF EVIDENCE: 3.

The subalar graft and its role in nasal tip medialization and improved nostril symmetry.

OBJECTIVES: Relationships between nasal axis deviation and lower midfacial asymmetry or hypoplasia have been established in prior studies. We describe our experience with the subalar grafting technique in addressing nasal tip deviation associated with facial asymmetry. Indications in using this graft in isolation or in conjunction with other tip modification techniques are also investigated. STUDY DESIGN: Retrospective case series. SETTING: Academic medical center. SUBJECTS AND METHODS: Thirty-seven consecutive patients from a single surgeon (R.W.W.) treated using subalar grafting are evaluated for correction. Various measurements from preoperative and postoperative photographs are analyzed to determine the effectiveness of this intervention. RESULTS: Statistically significant correlations between improvement in nasal axis and alar-facial angle on base view (AFAB) (P < .001) and between alar-facial angle on frontal view (AFAF) (P = .017) were observed. In addition, a significant correlation between AFAB improvement and AFAF normalization was observed (P < .001). The improved nostril symmetry was significantly correlated with base view correction and was not the result of general improvements in nasal deviation. CONCLUSION: While measuring the independent effects of subalar grafting is limited due to contaminant procedures, it can be recognized as a foundation rhinoplasty technique that, in conjunction with septoplasty, provides medialization of the tip in patients with facial asymmetry. Furthermore, aesthetic correction of nostril horizontal dystopia and/or nostril "show" is achieved with the proper application of this technique. This correction represents a unique intervention in rhinoplasty and should be considered a second indication for its use.

The effect of facial asymmetry on nasal deviation.

The impact of facial asymmetry on nasal deviation is an accepted but poorly understood part of plastic surgery and rhinology training. Recently, an increased understanding of the specific structural issues underlying this deformity has led to improved surgical techniques and patient outcomes.

Effect of midfacial asymmetry on nasal axis deviation: indications for use of the subalar graft.

OBJECTIVE: To test the hypothesis that midfacial asymmetry specifically relevant to nasal tip deviation will be reflected in the measured soft-tissue attachments of the ala to the face. DESIGN: Retrospective photographic analysis of 35 consecutive patients seeking functional or aesthetic nasal surgery regardless of cause. RESULTS: Nasal axis had a significant correlation with the alar-facial angle on base view photographs (P < .001) irrespective of cause (traumatic vs congenital). However, there was no significant correlation between alar facial angle on anteroposterior view (frontal) with nasal axis and no correlation between frontal and basal angles. CONCLUSION: Soft-tissue analysis demonstrates a relationship between nasal axis deviation and lower midfacial asymmetry or hypoplasia.

Is Susac syndrome (microangiopathy of the inner ear, retina, and central nervous system) an underdiagnosed cause of sensorineural hearing loss?

Susac syndrome is a rare disorder caused by the development of microangiopathic lesions in the inner ear, retina, and central nervous system. Although relatively few cases have been reported in the literature, this diagnosis is becoming more frequent as physician awareness increases. A high index of suspicion is needed to make the diagnosis because the signs and symptoms of Susac syndrome are those of a wide range of differential diagnoses. Otolaryngologists should be familiar with this syndrome because hearing loss may be the initial presenting symptom. We describe a new case of Susac syndrome to further promote physician awareness, and we discuss the options for diagnosis and treatment.

The tripod theory of nasal tip support revisited: the cantilevered spring model.

OBJECTIVE: To extrapolate on the tripod concept to create a more universal and multiethnic model that includes common anatomical configurations and strategies to avoid certain unwanted surgical outcomes. METHODS: Analysis of current surgical methods, scientific studies, and predominant theories to produce a new model of nasal tip support based on the biomechanical properties of the nasal cartilages. RESULTS: The nasal tip acts as a cantilevered spring that associates with other rigid and semirigid regions of the nose. Application of these concepts resulted in preservation of projection and tip rotation in appropriately selected patients. CONCLUSION: The cantilevered spring tripod provides a more universal model for explaining nasal tip dynamics in a contemporary multiethnic population of patients seeking functional or cosmetic rhinoplasty correction.

Augmentation of nasal tip projection using the inferior turbinate: review of technique and evaluation of long-term success.

OBJECTIVES: To introduce the use of inferior turbinate bone as an alternative autograft for augmentation of nasal tip projection and to assess maintenance of nasal tip projection, bone remodeling, graft shaping, and ease of harvesting. METHODS: Thirteen consecutive patients in need of increased nasal tip projection underwent closed rhinoplasty during a prospective nonrandomized study in a university teaching hospital setting. An autologous demucosalized inferior turbinate bone graft was used as a columellar strut. Measurements of nasal tip projection were obtained using the Goode ratio. Photodocumentation and lateral soft tissue radiographs were obtained before surgery and between 30 and 38 months after surgery. RESULTS: In all patients, the results were as follows: (1) the inferior turbinate bone graft was easily harvested and molded into the appropriate-sized columellar strut; (2) the immediate postoperative nasal tip projection, as measured by the Goode ratio and visual assessment, was increased; and (3) the tip projections were maintained at the 30-month follow-up examination. Paired t tests revealed a statistically significant difference (P = .001 and P = .009) between preoperative and both immediate and long-term measurements. Comparison of immediate postoperative radiographs with those taken 2 years later demonstrated no remarkable change in appearance of the graft. CONCLUSIONS: The interior turbinate bone is a viable graft for augmenting nasal tip projection. Moreover, it maintains tip projection and needs little to no remodeling. The graft is easy to harvest, prepare, and place and can be used without requiring a second operative site.

Correction of caudal deflections of the nasal septum with a modified Goldman septoplasty technique: how we do it.

Correcting deviations of the caudal septum can be challenging because of cartilage memory, the need to provide adequate nasal tip and dorsal septal support, and the longterm effects of healing. The authors describe a minimally invasive, endonasal approach to the correction of caudal septal deviations. The procedure involves a hemitransfixion incision, unilateral flap elevation, and cartilage repositioning by limited dissection and excision.

Defining nasal cartilage elasticity: biomechanical testing of the tripod theory based on a cantilevered model.

OBJECTIVE: To define the modulus of elasticity for nasal septum, auricular, upper lateral, and lower lateral cartilages. METHODS: Prospective enrollment of sequential patients undergoing septorhinoplasty. Test samples were obtained through routine surgical interventions using atraumatic harvesting techniques. The modulus of elasticity was determined using a customized biomechanical testing device. A clinical analysis of nasal tip strength and "ethnic" nasal categorization was performed. RESULTS: Five sequential patients were enrolled; 4 underwent biomechanical testing of harvested cartilage. All 4 patients were classified as having a leptor-rhine nasal architecture. The modulus of elasticity for the lower lateral cartilages was 1.82 to 15.28 MPa. Values for auricular, nasal septum, and upper lateral cartilages (medial and caudal) were also determined. CONCLUSIONS: This is the first biomechanical study performed on human auricular, lower lateral, and upper lateral cartilages. The elastic modulus can be determined from samples obtained during routine septorhinoplasty. The modulus of elasticity for all areas was significantly higher than values previously demonstrated for bioengineered elastic cartilage and carved human nasal septal specimens. Shaving the lateral portions of the nasal septum may significantly reduce tensile strength, which may affect graft performance in vivo. Further refinement of testing methods and an increase in the number of analyzed samples are required for formal statistical analysis and further determination of clinical relevance in different nasal subtypes.

Negative-pressure pulmonary edema after routine septorhinoplasty: discussion of pathophysiology, treatment, and prevention.

OBJECTIVE: To provide rhinologic surgeons with an understanding of acute negative-pressure pulmonary edema (NPPE) and its treatment. DESIGN: Case report and literature review of all published adult cases of NPPE. Patient factors, anesthetic variables, and outcomes are assessed. RESULTS: A total of 146 cases in 45 case reports and series were compiled. There was approximately a 2:1 male-female patient ratio. The average age of the patients was 33 years. Fifty percent of patients had surgery on the upper aerodigestive tract, and 8% had intranasal surgery. No patients received laryngotracheal anesthesia, and 5 of the 146 received intravenous lidocaine prior to extubation. One patient had NPPE following laryngeal mask airway treatment, and 2 patients experienced this complication after conversion from monitored anesthesia care to general endotracheal anesthesia; 33.5% of patients were treated with continuous positive airway pressure alone, while 66.5% required intubation and mechanical ventilation. The average time to resolution was 11.75 hours. Three patients died. CONCLUSIONS: It is known that surgical procedures involving the upper aerodigestive tract have a higher risk of NPPE than other procedures. Rapid diagnosis and treatment is necessary to achieve early resolution and avoid significant patient morbidity. A thorough understanding is integral to the practice of nasal and paranasal sinus surgery, especially with the rising use of outpatient and office-based surgical suites. Therefore, we present a review of pathophysiologic mechanisms, possible risk factors, treatment options, and potential steps that can be taken to minimize this potentially devastating complication of general anesthesia.

Perforating double lateral osteotomy.

Reshaping of the bony vault in primary and revision rhinoplasty is a simple, yet precise, maneuver that requires both skill and experience in creating predictable outcomes. Different methods for remodeling the nasal pyramid using various types of osteotomies have been devised to achieve narrowing, straightening, and reduction in nasal height. However, the current options of techniques including medial, transverse oblique, low to low lateral, low to high lateral, and intermediate osteotomies do not address all types of deformities encountered. These include the wide pyramid, the prominent frontal process of the maxilla, the convex nasal bone, and the deviated nose. Accordingly, the senior author has devised a new procedure, named the "perforating double lateral osteotomy," that has been used on hundreds of patients, with excellent results.

Midline necrotizing nasal lesions: analysis of 18 cases emphasizing radiological and serological findings with algorithms for diagnosis and management.

BACKGROUND: The aim of this study was to assess the principal signs and symptoms for severe necrotizing midline nasal lesions and give diagnostic and management algorithms. METHODS: Literature review and retrospective chart review were performed. Three patients with Wegener's granulomatosis (WG), six patients with sarcoid, eight patients with cocaine abuse, and one lymphoma patient were analyzed with respect to symptom complexes, laboratory results, and radiographic findings. Based on computed tomography findings, a nasal destruction score was tabulated for each patient. RESULTS: All diseases essentially had similar signs and symptoms within the head and neck but several extranasal sites were suggestive of specific etiologies. Serological laboratory testing was diagnostic in only two of the six sarcoid patients and two of the three WG patients. There were no specific tests associated with lymphoma or cocaine abuse, although erythrocyte sedimentation rate was consistently and significantly elevated in the latter group. Biopsy confirmed disease was found in one of the three sarcoid patients, in one of the three WG patients, and in one out of one of the lymphoma patients. Nasal destruction scores were highest in WG and lymphoma patients, intermediate in cocaine abuse patients, and lowest in patients with sarcoidosis. Two of the three WG patients had extensive neoosteogenesis. One out of one lymphoma and five of the eight cocaine abuse patients had oronasal or oroantral fistulas. CONCLUSION: Laboratory tests and biopsies were consistently unreliable in all diseases. Repeat studies should be performed in all cases of negative results if clinical suspicion is high. Neo-osteogenesis and mastoid disease were associated with WG when compared with patients with similar levels of nasal destruction due to other etiologies. Laryngeal and dermatologic changes without significant nasal bony abnormalities raised suspicion for sarcoidosis. Hard and soft palate defects were associated with cocaine abuse and extranodal nasal lymphoma.

Autologous cartilage grafts enhanced by a novel transplant medium using fibrin sealant and fibroblast growth factor.

OBJECTIVE: To introduce and assess a system for the delivery of fibroblast growth factor to autologous cartilage grafts using fibrin sealant and analyze whether this "enhancement" results in reduced rates of cartilage resorption and greater preservation of normal architectural features compared with "unenhanced" cartilage grafts. METHODS: Auricular cartilage segments measuring 1 cm(2) were harvested from 12 New Zealand white rabbits, morselized, and implanted into the subcutaneous dorsum of the upper back for 3 months. The conditions included (1) cartilage alone; (2) cartilage + fibrin sealant; (3/4) cartilage + acidic or basic fibroblast growth factor (aFGF or bFGF); and (5/6) cartilage + fibrin sealant + aFGF or bFGF. Subsequent to graft harvest, gross and microscopic assessments were performed to assess size, structural integrity, and architectural features, with comparisons performed between each of the conditions. RESULTS: The mean areas of the harvested cartilage grafts treated with fibrin sealant + aFGF or bFGF were 1.23 cm(2) and 1.19 cm(2), respectively, while the corresponding value for the untreated (ie, cartilage alone) specimens was 1.03 cm(2). The percentage of decrease in size was 45% for the untreated specimens and 0% for the specimens treated with fibrin sealant + aFGF or fibrin sealant + bFGF. Cartilage treated with fibrin sealant + bFGF had the greatest quantity of elastin fibers of the 6 conditions. Cartilage grafts treated with fibrin sealant alone demonstrated the most intense ground substance staining on a computerized measure of pixel intensity. CONCLUSIONS: Our findings demonstrated significant improvements in graft quality using fibroblast growth factor and fibrin sealant or even fibrin sealant alone. These findings may justify changes in how cartilage grafts are prepared and delivered for facial augmentation procedures to reduce graft resorption and maintain the structural integrity of the cartilage. Further trials will be performed to elucidate the optimal growth factor concentrations for maximum structural and architectural benefits.

Preoperative parathyroid localization: correlating false-negative technetium 99m sestamibi scans with parathyroid disease.

OBJECTIVE/HYPOTHESIS: The recent trend toward minimally invasive directed parathyroid surgery has increased the surgeon's reliance on preoperative parathyroid localization. Technetium Tc 99m sestamibi scanning is generally viewed as the gold standard for preoperative localization, with reported sensitivities of 75% to 100% and specificities of 75% to 90%. However, in each reported series there exists a group of patients in whom preoperative localization is either equivocal or negative. STUDY DESIGN: We focused on a subset of patients from our parathyroid database with false-negative sestamibi (MIBI) scans, in an attempt to elucidate features that could affect these studies. We identified 20 patients with negative preoperative scans and confirmed parathyroid disease. We compared them with 22 consecutive patients with positive scans, correlating the following variables: patient age, gender, concomitant thyroid disease (Hashimoto's thyroiditis, papillary thyroid carcinoma, thyroid adenoma), preoperative parathyroid hormone values, location and number of enlarged parathyroid glands, parathyroid weight, and the relative proportion of chief cells, clear cells, oxyphil cells, and adipose tissue. METHODS: Retrospective chart review of clinicopathological and radiological findings. RESULTS: We found that patients with false-negative scans were more likely to have an enlarged parathyroid containing a high proportion of clear cells (P =.01). A trend was seen (P =.1) correlating increased parathyroid fat content and false-negative scans. Conversely, positive preoperative scans were more likely to be associated with a higher percentage of oxyphil cells (P =.02). Univariate analysis for other variables, as well as logistic regression analysis, did not achieve statistical significance. CONCLUSIONS: To date, the present study is the largest clinicopathological review of patients with false-negative sestamibi scans. Technetium Tc 99m uptake correlates with parathyroid oxyphil cell content, and false-negative scans can occur with parathyroid glands containing predominantly clear cells.