Saddle Nose Deformity Reconstruction with a Allograft Bone.

OBJECTIVE: Providing lasting cosmetic and functional results for patients with saddle nose deformity with allograft. METHODS: This report describes experience with using a of freeze-dried allograft bone allograft in 58 patients who underwent dorsal augmentation over 5-year period (2018-2023). Thirty-eight patients had saddle-shaped deformity of the nose, and 16 patients had post-traumatic cases with saddle nose deformities. All patients underwent a clinical examination using computed tomography. Before surgery using a 3D model, the graft was contoured according to the shape of the nasal defect. The grafts were installed using a closed approach and were placed under the periosteum of the bone. Using lateral photographs, anthropometric measurements of the nose were taken before and after surgery to assess aesthetic outcome after surgery. To assess the results of aesthetic rhinoplasty (UQ), the Portuguese version of the Utrecht Questionnaire was used, which contains a visual analogue scale (VAS) on a 5-point Likert scale. RESULTS: A total of 56 patients were satisfied with the results of the surgical procedure. No complications or major graft resorption was observed. An analysis comparing preoperative and 1-year follow-up data using 3D scanning showed a significant increase in dorsal height without dorsal expansion. After rhinoplasty, the mean visual analog scale (VAS) aesthetic score improved significant from 2.3 preoperatively, 3 months postoperatively 8.4, and 8.9 1 year postoperatively. CONCLUSION: The use of freeze-dried allograft bone is a useful method of dorsal augmentation in rhinoplasty without donor site complications. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Innovative Non-Surgical Plastic Technique for Saddle Nose Correction: A Study on 97 Patients.

Background: Non-surgical rhinoplasty is one of the best choices in mild cases of the saddle nose, and it represents a solution for the aesthetical amelioration of facial deformity; nevertheless, in most critical cases, surgical intervention is still required. This study reports the experience and results of a single facial plastic surgeon (M.G.) using a non-surgical technique for the correction of saddle noses in a large cohort of patients. Methods: This retrospective study assesses all patients injected from January 2017 through October 2023 in private clinics in Milan (Italy), London (UK), and Dubai (UAE). All patients were followed up for 12 months. The harvested adipose tissues were processed with different systems and with or without acoustic wave therapy (AWT). The extracted products have been characterized in terms of cellular yield and cell growth. Ninety-seven patients were injected with adipose-derived products or hyaluronic acid (HA). Patients were followed up for 12 months, and satisfaction data were analyzed. Results: The stem cells obtained from the patients who previously received AWT displayed a statistically higher cell growth ability in comparison with those of the cells derived from patients who did not receive AWT. The evolution of patient satisfaction during the time for each group of treatment was investigated, and cellular treatments show the best maintenance of patient satisfaction over time. Conclusions: Dermgraft and AWT approaches resulted in the highest patient satisfaction for the non-surgical correction of the saddle nose deformity.

Saddle Nose Deformity in a Patient With Crohn's Disease.

Crohn's disease is a chronic inflammatory disorder of the gastrointestinal tract, frequently presenting with extraintestinal manifestations. Granulomatosis with polyangiitis is a systemic vasculitis primarily affecting the respiratory tract and kidneys. Extraintestinal Crohn's disease and granulomatosis with polyangiitis may have similar clinical presentations and, in rare occurrences, can coexist. This case report highlights the diagnostic and therapeutic complexities of this uncommon overlap syndrome.

Pediatric-Onset Relapsing Polychondritis With Otolaryngeal Manifestations.

Relapsing polychondritis (RP) is a rare autoimmune disease that can present with various clinical manifestations. Among the affected sites, the ear, nose, and throat cartilages are frequently involved, often leading to subtle and episodic symptoms that can be challenging to diagnose. A high index of suspicion is necessary for the early identification of these subtle signs, which can aid in early diagnosis and prompt management. In this report, we present a rare case of pediatric-onset relapsing polychondritis that was initially misdiagnosed as laryngotracheobronchitis.

Relapsing Polychondritis: A Rare Case Report.

Relapsing polychondritis is an uncommon disorder of unknown cause characterized by inflammation of cartilage, predominantly affecting the ear, nose, and laryngotracheobronchial tree. The case under discussion is a 50-year-old female with a classical presentation of relapsing polychondritis with saddle nose deformity, bilateral auriculitis, and laryngotracheobronchomalacia with joint involvement.

Characterization of the Saddle Nose Deformity Following Endoscopic Endonasal Skull Base Surgery.

Objective The endoscopic endonasal approach (EEA) is commonly employed in skull base surgery for neoplasm resection. While nasal deformity following EEA is described, this study aimed to perform a detailed qualitative and quantitative assessment of the associated saddle nose deformity (SND) in particular. Setting/Participants This is a retrospective review of 20 adult patients with SND after EEA for resection of skull base tumors over a 5-year period at the University of Pittsburgh Medical Center. Main Outcome Measures Fifteen measurements related to SND were obtained on pre- and postoperative imaging. Statistical analyses were performed to evaluate differences between pre- and postoperative anatomies. Results The most common EEA was transsellar. Reconstruction techniques included nine free mucosal grafts alone, eight vascularized nasoseptal flaps (NSFs), one combined free mucosal graft/abdominal fat graft, and one combined NSF/fascia lata graft. Imaging analysis showed a trend toward loss of mean nasal height, nasal tip projection, and nasolabial angle postoperatively. Subgroup analysis showed that patients with NSF reconstruction had a significantly decreased nasal tip projection (1.2 mm, p = 0.039) and increased alar base width (1.2 mm, p = 0.046) postoperatively. Patients without functional pituitary microadenomas demonstrated significantly increased nasofrontal angle and decreased nasal tip projection on postoperative imaging, in contrast to those with functional adenomas who had no measurable significant changes. Conclusion Clinically evident SND does not always lead to significant radiographic changes. This analysis suggests that patients who undergo surgery for indications other than functional pituitary microadenomas or who receive NSF reconstruction develop more marked SND on standard imaging tests.

Impact of Reverse Septal Flap on Morbidity of Nasoseptal Flap Reconstruction of Skull Base Defects.

BACKGROUND: The workhorse for endonasal reconstruction of skull base defects is the posteriorly-based nasoseptal flap (NSF). Postoperative nasal deformities and decreased olfaction are potential complications of NSF. The reverse septal flap (RSF) minimizes the donor site morbidity of the NSF by covering the exposed cartilage of the anterior septum. Currently, there are minimal data examining its effect on outcomes including nasal dorsum collapse and olfaction. OBJECTIVE: Our study aims to clarify whether the RSF should be utilized when the option exists. METHODS: Adult patients undergoing endoscopic endonasal approach (EEA) surgery of the skull base (transsellar/transplanum/transclival approaches) with NSF reconstruction were identified. Data from 2 separate cohorts, one retrospective and one prospective, were collected. Follow-up was at least 6 months. Patients were photographed preoperatively and postoperatively using standard rhinoplastic nasal views. Patients completed the University of Pennsylvania Smell Identification Test (UPSIT) and the 22-item Sino-Nasal Outcome Test (SNOT-22) preoperatively and postoperatively and were also queried regarding subjective changes in nasal appearance and plans for cosmetic surgery following EEA. RESULTS: There were no statistically significant differences in the change in UPSIT and SNOT-22 scores between patients receiving RSF and other reconstructive groups (either NSF without RSF or no NSF). One of 25 patients who were reconstructed with an NSF with RSF reported a change in nasal appearance; none were considering reconstructive surgery. The proportion of patients reporting changes in appearance was significantly lower in the NSF with RSF group as compared to the NSF without RSF group (P = .012). CONCLUSION: The use of an RSF to limit donor site morbidity of the NSF was shown to significantly decrease the proportion of patients who reported nasal deformities and did not show a significant difference in patient-reported sinonasal outcomes. Given these findings, RSF should be considered whenever an NSF is used for reconstruction.

Reconstructive rhinoplasty using cadaver cartilage in relapsing polychondritis.

Relapsing polychondritis is a rare autoimmune disorder of unknown cause characterized by recurrent inflammation of cartilage predominantly affecting the ears, nose, and upper airway. The bridge of the nose and surrounding tissue can collapse, producing a saddle nose deformity. Nasal reconstruction is often challenging in these patients due to impaired wound healing and graft take caused by autoimmune inflammatory disease and prolonged immunosuppressant treatment. Many different reconstruction techniques like autologous rib, fascia lata, and calvarial bone grafts have been used. Herein we report the use of a cadaver cartilage graft in a 55-year-old woman with relapsing polychondritis and saddle nose deformity. Because of the characteristic chondritis of her autoimmune condition, cadaver cartilage was selected because it is antigenically different from the patient's own cartilage, offering significant structural integrity for nasal reconstruction compared to other techniques.

Subdorsal Cantilever Graft: Indications and Technique.

The subdorsal cantilever graft (SDCG) is a costal cartilage graft that is positioned below the nasal dorsum to control the position of the nasal bones and middle nasal vault. SDCG type A is used to raise the middle nasal vault and caudal nasal bones to correct the saddle nose deformity. SDCG type B can be used to raise the entire dorsum of the nose (radix, bony vault, and middle vault) in the ethnic augmentation rhinoplasty patient. This article will discuss the indications and technique of the SDCG in dorsal preservation rhinoplasty.

Inferior Turbinate Bone Graft for Dorsal Augmentation in Rhinoplasty.

The most serious form of nasal dorsum pathologies is saddle nose deformity. Vary of nasal dorsal augmentation grafts were reported in the literature but inferior bone graft (ITBG) alone has not attracted attention. The ITBG has advantages such as easy and fast harvesting, easy to shape due to cancellous bone tissue. The graft technique is similar to the inferior turbinoplasty with the medial mucosal flap technique and can be performed without bioabsorbable hemostatic material (e.g. Turkish Delight), suture fixation, or without tissue adhesives. Major complications of the ITBG technique are injury of the posterior lateral nasal branch of the sphenopalatine artery and subdermal mucous cyst that developing on nasal dorsum. Since easy application, fast harvesting, and similar permanence to cartilage grafts as augmentation material, ITBG can also been used successfully in minor dorsal deficits in addition to saddle nose deformities.

Nasal Septal Mucocele Causing Saddle Nose Deformity.

Nasal septal mucoceles are a rare occurance, and reports in the current literature are limited. We describe the case of a 73-year-old woman who developed a nasal septal mucocele several days after an episode of angioedema. The lesion was treated with 2 rounds of needle aspiration with antibiotics and the application of silastic splints. There was no recurrence after 1 month, though the patient developed a saddle nose deformity. She ultimately underwent reconstruction with a diced-cartilage dorsal augmentation graft with fibrin glue. We review the learning points of this case and summarize existing literature on this disease.

Nasal septal hematoma in children: Time to diagnosis and resulting complications.

OBJECTIVES: To determine the time from initial injury to diagnosis of nasal septal hematoma (NSH). Additional objectives included determining number of medical evaluations prior to diagnosis and long-term complications. METHODS: A retrospective chart review was performed on all patients diagnosed with NSH at a tertiary pediatric hospital between January 1, 2003 and April 1, 2019 were identified. Time to diagnosis was defined as time between initial trauma to date of diagnosis. Number of evaluations was defined as all medical evaluations prior to diagnosis. RESULTS: Of 2762 charts that were reviewed, 13 patients with NSH were identified. Of those, 92% were male and trauma was the cause in 85% of patients. Median time to diagnosis was 7 days (0-21 days), with an average of 2.2 evaluations (1-4 evaluations). Settings where diagnosis were missed included EDs (N = 9, 82%), primary care (N = 6, 55%), urgent care (N = 1, 9%) and otolaryngology clinic (N = 2, 18%). Four patients (31%) were evaluated by an otolaryngologist in the ED. The median time to otolaryngology outpatient visit was 7.5 days. In five patients (46%), septal hematomas were missed in multiple clinical settings. Seven patients (54%) experienced complications, including saddle nose deformity (N = 3, 23%). CONCLUSIONS: NSH is a rare but serious emergency. To avoid multiple visits and delay in diagnosis, additional education and awareness is needed for providers who evaluate these patients. Early diagnosis will reduce the risk of abscess formation and saddle nose deformity.

Harvesting Split Costal Cartilage Graft in Revision Rhinoplasty Without Disturbing the Costal Integrity.

BACKGROUND: Graft use is inevitable in some primary and secondary rhinoplasty cases with cartilage or bone deficiency. Although rib graft is one of the best graft sources, it has several disadvantages. The purpose of this study is to minimize the risks of using rib grafts. MATERIAL AND METHODS: Between 2018 and 2020, a total of 21 patients aged between 25 and 55 have undergone revision rhinoplasty under general anesthesia with a split cartilage graft of central origin. A 3-4-mm-thick bridge was left at the superior and inferior edges of the donor area, and the graft was harvested from the central region without disrupting the costal integrity. A special retractor was placed between the perichondrium and the rib at the posterior of the costa to prevent damage to the pleura while cutting the rib. The previously marked grafts were cut in the donor area and harvested ready for use. The harvested grafts were used as spreader, strut, alar rim and nasal valve grafts. RESULTS: None of the patients had complications due to rib graft harvesting. After the operation, pain in the donor region and analgesic requirement of these patients were less compared to the patients with full-layer grafts. CONCLUSIONS: The grafts taken from the center of the costa without breaking its integrity seem quite suitable for revision rhinoplasty surgeries. This technique prevents various morbidities and enables patients to have a more comfortable postoperative period. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Impact of baseline clinical and radiological features on outcome of chronic rhinosinusitis in granulomatosis with polyangiitis.

BACKGROUND: Granulomatosis with polyangiitis (GPA) causes a recurring inflammation in nose and paranasal sinuses that clinically resembles chronic rhinosinusitis (CRS) of other aetiologies. While sinonasal inflammation is not among the life-threatening features of GPA, patients report it to have major negative impact on quality of life. A relatively large proportion of GPA patients have severe CRS with extensive damage to nose and sinus structures evident by CT, but risk factors for severe CRS development remain largely unknown. In this study, we aimed to identify clinical and radiological predictors of CRS-related damage in GPA. METHODS: We included GPA patients who had clinical data sets from time of diagnosis, and two or more paranasal sinus CT scans obtained ≥12 months apart available for analysis. We defined time from first to last CT as the study observation period, and evaluated CRS development across this period using CT scores for inflammatory sinus bone thickening (osteitis), bone destructions, and sinus opacifications (here defined as mucosal disease). In logistic regression, we applied osteitis as main outcome measure for CRS-related damage. RESULTS: We evaluated 697 CT scans obtained over median 5 years observation from 116 GPA patients. We found that 39% (45/116) of the GPA patients remained free from CRS damage across the study observation period, while 33% (38/116) had progressive damage. By end of observation, 32% (37/116) of the GPA patients had developed severe osteitis. We identified mucosal disease at baseline as a predictor for osteitis (odds ratio 1.33), and we found that renal involvement at baseline was less common in patients with severe osteitis at last CT (41%, 15/37) than in patients with no osteitis (60%, 27/45). CONCLUSIONS: In this largely unselected GPA patient cohort, baseline sinus mucosal disease associated with CRS-related damage, as measured by osteitis at the end of follow-up. We found no significant association with clinical factors, but the data set indicated an inverse relationship between renal involvement and severe sinonasal affliction.

Nose like the foot of a pot.

Saddle nose is defined as a depression of the nasal dorsum, regardless of its dimensions or the anatomical structures involved. The purpose of this historical note is to discuss the term "nose like the foot of a pot (nez en pied de marmite)" used to describe this deformity in France between the 17th and 19th centuries and to recall its link with syphilis in the light of the texts of the time.

Augmentation rhinoplasty using olecranon bone graft.

BACKGROUND: Correction of saddle nose deformity is one of the most frequently sought surgeries by patients seeking rhinoplasty in Asian countries. Nasal dorsal augmentation always requires graft material to achieve the desired result. Various autologous grafts and alloplastic materials have been described in the literature with their advantages and disadvantages. We report our study on the use of olecranon bone graft for augmentation rhinoplasty in severe saddle nose deformity and discuss our experience with it. MATERIALS AND METHODS: In this observational study, 12 patients who underwent dorsal nasal augmentation using olecranon bone graft from August 2011 to December 2020 were studied. All ten patients with congenital deformity underwent graft insertion through a closed rhinoplasty approach, whereas two patients with posttraumatic deformity were operated through old scars over the nasal dorsum. The graft was fixed with screws at nasion in both posttraumatic cases. All the patients were evaluated postoperatively at regular intervals for graft resorption by clinical photographs and X-ray nasal bone. RESULTS: The age ranged from 20 years to 48 years. No immediate complications related to graft placement were noted. One patient had a hairline fracture of the ulna at the donor site on the 3rd postoperative day which was managed conservatively with a cast. The mean follow-up period was 2 years. No nasal dorsum projection loss or signs of bone resorption were observed for up to 5 years after surgery. One patient with posttraumatic deformity required removal of fixation screw which got exposed after 2 years of surgery. CONCLUSION: Olecranon bone graft is a suitable material for nasal dorsal augmentation in severe saddle nose deformity because of ease of harvest and minimal donor area morbidity. The appropriate thickness of the cortex of the olecranon process allows custom molding and provides resistance to resorption in long term, thereby giving a desirable outcome.

Review of literature of saddle nose deformity reconstruction and presentation of vomer onlay graft.

OBJECTIVE: Saddle nose deformity is a well-described condition that most commonly results from trauma or prior surgery. For larger saddle nose deformity defects, bone grafts are a reconstructive option that provide adequate structure for repair. One new technique for repair of these deformities is a vomerian bone onlay graft. We aim to provide a review of literature on autogenous repair of saddle nose deformities, as well as introduce a new technique in which the vomer bone is used as an onlay bone graft. METHODS: Literature review and case series. Five cases in which vomer onlay grafts were used for repair of saddle nose deformity were reviewed between January 2013 and December 2015. Aesthetic outcomes and postoperative complications were evaluated at subsequent follow-up visits in clinic. RESULTS: In all cases where vomer bone was harvested, the vomer onlay graft provided adequate structure to traverse the saddle nose deformity. No postoperative complications were observed in an 18 month follow-up period. CONCLUSION: Vomerian bone onlay grafts are a reconstructive option for saddle nose deformity and nasal dorsum defects. While septal cartilage is commonly used, and ethmoidal bone has been previously described as an option for composite graft reconstruction, vomer bone onlay grafting has not been well described in the literature. This method may be of use when previous nasal surgery has been performed and standard septal cartilage is not possible to harvest. The aesthetic outcomes following nasal dorsum reconstruction using onlay grafts are favorable, but long-term outcomes of these grafts require further study. LEVEL OF EVIDENCE: IV.

Clinical application of the 6th autogenous costal cartilage in the treatment of severe saddle nose deformity after trauma. / 第6自体肋软骨在外伤后重度鞍鼻畸形修复中的临床应用.

OBJECTIVES: Saddle nose deformity is a common clinical nose deformity. This study aimed to evaluate the effectiveness of the 6th autogenous costal cartilage in the treatment of severe saddle nose deformity after trauma. METHODS: A retrospective analysis was conducted on 15 patients with severe post-traumatic saddle nose deformity from March, 2016 to March, 2019. The nasal tip and dorsum were reconstructed with autogenous costal cartilage. All patients were followed up for 6 to 13 months and changes in nasal appearance were evaluated. The changes in dorsum sag, nasolabial angle, nasal dorsal angle, and dorsum length were measured. RESULTS: Fourteen patients were basically satisfied with post-operative outcome. Only one patient developed infection afterwards, which was improved by the revised rhinoplasty 2 months after active treatment. The immediate nasal dorsal depression [(1.19±0.94) mm] and nasolabial angle [(94.06±1.52)°] after operation decreased compared with those before surgery [(8.28±0.24) mm, (109.42±2.78)°, respectively; all P<0.05]. The immediate nasal dorsal length [(44.18±1.02) mm] and nasal dorsal angle [(132.84±2.33)°] increased compared with those before operation [(31.73±1.86) mm, (122.87±2.42)°, respectively; all P<0.05]. The data at follow-ups showed no statistical difference compared with the immediate data after operation. CONCLUSIONS: Rhinoplasty with the 6th autogenous costal cartilage is an effective method for the correction of severe saddle nose deformity after trauma.

Augmentation Rhinoplasty Using Iliac Crest Graft in Saddle Nose Deformity.

Autologous bone graft is one of the management solutions for saddle nose deformity. This helps from both functional and esthetic perspective. Several features of autologous graft specify the best material used to repair bony and cartilaginous nasal defects. This article describes a case of a female who presented with saddle nose deformity after incidental insertion of a button battery in her nostril during childhood which was followed by depressed nasal dorsum. It was managed with good outcomes by augmentation rhinoplasty using an iliac crest bone graft.