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.

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.

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.

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.

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.