The nasal tip constitutes the mobile portion of the nose, in direct contraposition to the pyramid that is a fixed structure. Its configuration, position, and shape are derived mainly from the outline and from the thickness of the wing cartilages, important elements of the nasal tip, that together with skin and subcutaneous tissue can deeply influence the configuration and dynamics of this section of the nose as well. In reshaping the nasal tip, 2 fundamental concepts must be considered: projection and rotation; these may be modified, acting on the nasal cartilaginous framework and/or on the superficial nasal fibromuscular structure (SMAS). The aims of this study are to evaluate the nasal tip changes in terms of rotation and projection obtained just acting on superficial muscle aponeurotic deep medial layer without performing any dissection or modification of the nasal tip framework, and to try to explain these possible changes according to the SMAS structure rearrangements only. Twenty-one patients (18 female and 3 male) were subjected to closed rhinoplasty, without tip cartilage dissection/modification. Preoperative and postoperative tip rotation angle, nasolabial angle, and tip projection were measured. The only tip procedure performed was the resection of the SMAS deep medial layer. Our results show significant rotation of the nasal tip and no statistically significant tip deprojection.

While the use of crushed cartilage is now universally recognized as a valid procedure in rhinoplasty to mask irregularities and eliminate slight deficits, there is still no consensus as to the optimal degree of crushing and the rate of graft resorption over time. With a view to casting light on these 2 important aspects and providing some guidelines, the authors present a study of 123 patients subjected to grafts of cartilage with different degrees of crushing in the different areas of the nasal pyramid: upper third (45 patients), middle third (40), and lower third (38). The degree of crushing was medium for 95 patients and high for 28 who presented thinner and less elastic skin. Comparison of the performance over time of the cartilage grafts inserted in the same areas but with different degrees of crushing provides important indications as regard the best way of preparing the material. The results proved satisfactory with improvements for all of the 95 patients subjected to grafts of moderately crushed cartilage. The initial defect was instead still present, albeit with some partial improvement, at a distance of 12 months in 17 of the 28 patients where highly crushed cartilage was used. The study suggests that a moderate degree of crushing offers better results as regard flexibility and stability over time.

Perfection is sometimes approached in treatment of the crooked nose today but not fully achieved due to the continued existence of flaws. While the traditional surgical algorithm envisages the use of 2 series of procedures to straighten the nasal bones and cartilaginous septum, the addition of a third appears very useful with a view to obtaining truly excellent results, above all in the case of marked deviation. The authors present their experience in the use of certain procedures designed to correct asymmetry of the upper lateral and lower lateral cartilages, as well as the soft covering tissues where necessary. A retrospective study was carried out on 105 patients treated for crooked nose over a 3-year period, 90% of the patients being due to trauma and the remaining 10% to congenital malformation. All the patients involved severe deviation of the nasal pyramid. The mean follow-up period was 18 months (range: 8-36 months). The use of these additional surgical procedures made it possible to obtain excellent final results in 83 (97.6%) patients with crooked nose of traumatic origin and in 17 (85%) patients with crooked nose due to congenital malformation. No major complication was registered, although 3 patients did present minor complications not connected with the nasal deviation. In conclusion, more modern approach to correction of the crooked nose should involve not only realignment of the osteocartilaginous axis but also treatment of the neighboring structures.

Secondary cleft lip nasal deformities corrective procedures are still a major concern for the maxillofacial surgeons.

Dome division can still be regarded as a valid surgical procedure today in some particular cases of revision rhinoplasty where the scarring is so extensive as to make precise isolation of the alar cartilages impossible. The presence of asymmetry of the nasal tip, a recurrent feature in the results of rhinoplasty, constitutes the primary indication, as division makes it immediately possible to restore balance between the two domes in such cases. The technique also proves useful in cases of overprojection of the tip as a result of rhinoplasty. Moreover, the procedure has been improved by precise suturing of the cartilaginous stumps so as to avoid its frequently reported complications, arising essentially from the vulnerability of the domal arch to the distorting forces of cicatricial retraction and its resulting lack of stability over time. In this connection, the authors attach crucial importance to direct suturing of the cartilaginous stumps in accordance with a now standardized method that is easy to execute and offers lasting, stable results. This approach makes it possible to re-establish continuity of the cartilaginous domal arch in a form unquestionably closer to the physiological anatomical conformation.

Background: The importance of analysis of the nasal spine should not be underestimated in the correct planning of rhinoplasty. Deformations in position with respect to the midline and/or in size are often present, and their correction to ensure harmony between the spine and the other components of the nasal pyramid constitutes a key step in rhinoplasty that can lead to excellent results.Methods: The study includes 160 patients who underwent surgical treatment of the anterior nasal spine with or without other techniques of nasal reshaping. Eighty-seven of these patients presented with hyperplasia of the nasal spine, 43 with hypoplasia, and 30 with deviation. A combination of deviation and hyperplasia was present in 15 cases.Results: No patients developed postoperative complications. Five patients who underwent anterior nasal spine reduction reported postoperative numbness in the premaxillary area, but sensitivity was fully regained within 4 months after surgery in these patients. All the patients reported postoperative improvement of nasal airflow. A total of 142 patients considered their postoperative aesthetic result as excellent and 18 as good.Conclusion: The simplicity of the surgical procedures performed on the nasal spine and the marked aesthetic improvements thus achieved suggest that greater attention should be paid to this anatomical region.

Loss of the cartilaginous nasal septum, a condition frequently encountered in the practice of nasal surgery, can vary in scale depending on its etiopathogenesis. Previous surgery, trauma, and infection can lead to subtotal absence of the septum with severe functional and aesthetic problems. Use of the auricular concha for reconstructive purposes proves an immediate and effective method making it possible to replace the missing tissue without involving operations of a more invasive nature. The fundamental problem in the use of the auricular concha is making this type of cartilage as similar as possible to the cartilaginous septum, endowing it with the structural strength and straightness required for support and the respiratory function. Surgical procedures with the use of figure-eight sutures and grafts of cartilage harvested from the concha prove capable of performing this major task of morphofunctional transformation. The article describes the phases involved in achieving the set objectives.

The nasal septum plays an important role in both the appearance and function of the nose. Deviation of the nose is common and correction requires a focused, anatomically based treatment. Reconstruction and support of the septum is a necessary component to a straight nose. The "four R's" of nasal septal repair-resection, reposition, reconstruction, and replacement-can be used to straighten the septum and maximize nasal appearance and function.

The Mediterranean nose possesses some specific characteristics of the ethnic group in question that can appear unduly accentuated in some cases and reflect a situation of authentic nasal deformity. The problems most frequently encountered consist of a prominent hump and protruding dorsum, a ptotic tip, an acute nasolabial angle, and thick, sebaceous skin. The surgeon in his approach to the Mediterranean nose must be able to recognize these deformities and to resolve them in accordance with the aesthetic canons peculiar to this ethnic group. To this end, this article describes prudent and progressive criteria for selection of the most appropriate techniques to correct the various flaws while seeking to preserve the structures as much as possible. Cartilage grafts can prove very useful with a view to ensuring both excellent results and their stability over time.

Irregularities in the nasal contour of patients who underwent multiple surgeries are frequently related also by skilled surgeons. The aim of this study was to describe the method of harvesting and the primary applications of erichondrium grafts in revision rhinoplasty to prevent postoperative irregularities.Conchal grafts were used in the reconstruction of structures missing as a result of rhinoplasty. The perichondrium was removed from the cartilage during harvesting and fixed on the cartilagenous grafts to fill up empty spaces and make uniform the surface of the grafts. These techniques were used on 62 patients.All of the patients treated showed aesthetic improvement with respect to the preoperative situation. Comparison with other cases in which the perichondrium graft was not used demonstrates its effectiveness in avoiding certain sequelae over time, especially as regards the presence of unattractive sharp edges often visible beneath the cutaneous covering after the use of structural grafts.In conclusion, perichondrium grafting during secondary rhinoplasty is an easily performed technique that involves a small increase in operating time if combined with the harvesting of conchal material. Its application over the surface of cartilage grafts constitutes a stable covering over time that protects the definitive result from irregularities caused by the disappearance of postoperative edema and scar retraction.

OBJECTIVE:To describe the barrel roll technique that is capable of concurrently correcting 2 associated deformities--overprojection and ptosis of the nasal tip.METHODS:Thirty-two patients with concavity of the upper section of 1 or both lateral crura combined with a droopy tip were treated from January 1, 2005, through December 31, 2007. In all cases, the barrel roll technique was used, which involves rotating the lateral crus by 180° on its major axis so that the concavity is transformed into convexity, and carrying out lateral crural overlay to correct the overprojection concurrently.RESULTS:All the patients displayed functional and aesthetic improvement by correcting the droopy tip and concavity of the lateral crura. Revision was necessary in 1 case of monolateral concavity. The comparison of preoperative and postoperative rhinomanometric data showed significant improvement of nasal airway resistance.CONCLUSIONS:A combination of the overlay technique and rotation of a portion of the lateral crus on its axis is capable of concurrently correcting serious functional problems and aesthetic defects of the nasal tip. The open approach is essential for perfect positioning of the mobilized cartilaginous segments and ensuring stable results over time.

Background: Middle-third facial implants are primarily indicated for facial plastic surgery and orthognathic surgery as well as the secondary treatment of facial trauma and congenital malformations. Several methods of clinical analysis have been described both for defect classification and for surgical technique and implant materials. These prove very difficult to apply so as to establish a precise standard. Methods: A new frontal-view facial analysis was developed on the basis of a grid of three vertical and five horizontal lines, divided in turn into six high and four lower middle-third areas with three vertical lines on side view. These vertical lines (LC and P) prove useful for the purposes of quantifying degree of defect. The lines can be marked on the patient’s face during the intraoperative phase so as to ensure correct implant placement. Medpor implants were applied and secured by means of circumvestibular incision during Le Fort I osteotomy with titanium miniscrews. Results: One hundred fifty-one patients with zygomatic defects were treated by means of this method during the correction of facial malocclusion. The results were achieved as planned during the preoperative phase in all cases. Postoperative complications were of minor severity, and only one implant was removed. Conclusions: This method of facial analysis is simple, and the drawing of lines proves useful to ensure correct implant positioning and symmetry during the surgical phase. In addition to being very easy to apply, position, and shape, Medpor implants also offer long-term stability and involve no any major complications.

Archives of Facial Plastic SurgeryVol. 10, No. 1 Surgical TechniquesFree AccessThe Lateral Crural Stairstep TechniqueA Modification of the Kridel Lateral Crural Overlay TechniqueArmando Boccieri and Giuseppe RaimondiArmando BoccieriCorrespondence: Armando Boccieri, MD, Viale Umberto Tupini 133, 00144 Rome, Italy E-mail Address: armando.boccieri@libero.itDepartment of Maxillofacial Surgery, S. Camillo Hospital, Rome, ItalySearch for more papers by this author and Giuseppe RaimondiDepartment of Otorhinolaryngology, United Hospitals, Livorno, ItalySearch for more papers by this authorPublished Online:1 Jan 2008https://doi.org/10.1001/archfacial.2007.7AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail The Kridel lateral crural overlay technique has proved capable of resolving overprojection with severe ptosis of the tip and can be used along with a medial crural overlay to reduce marked overprojection of the tip with no significant rotation. In the technique described herein, the section of the lateral crus involved in the lateral crural overlay is step-shaped rather than vertical and the cartilage is completely detached from the skin beneath as far as the domus. The anterior segment is moved downward and is overlapped with the posterior segment on both sides to resolve “parenthesis deformities” of the nasal tip that are caused by malposition of the lateral crura. This procedure can also be combined when necessary with both posterior and anterior sliding of the lateral crus to correct most deformities of the nasal tip. Within the framework of surgery on the nasal tip, attention has focused primarily on techniques that were designed to modify the projection and rotation of the nasal tip. It is only recently that a new parameter with important aesthetic and functional implications has emerged, namely cephalocaudal positioning in the space of the lateral crura.1Cephalic malpositioning of the lateral crura gives rise to a parenthesis deformity of the nasal tip that can manifest alone or along with defects of projection and rotation to varying degrees.2 The caudal margin of the lateral crura can also be anatomically oriented in a position markedly below the cephalic margin, which results in a lack of support for the alar lobule and the alar margin.3 In some cases, it is precisely the dome suturing that causes displacement of the caudal margin of the lateral crura beneath the cephalic margin. In others, the weakening of the domus that is sometimes caused by surgery makes it unable to resist the scar contraction that pushes the lateral crura upward. In all these situations, from an aesthetic viewpoint, there is a clear separation between the tip lobule and the alar lobule, with a pinched and unnatural appearance of the nasal contour. In functional terms, there can be respiratory difficulties of varying degree owing to insufficiency of the external nasal valve caused by lack of structural support for the alar margin.While careful preoperative clinical analysis can identify most situations of congenital or acquired malpositioning of the lateral crura, the precise scale of the pathologic condition is revealed only by direct intraoperative observation using open access. The corrective surgical technique must seek to reposition the lateral crura, bearing in mind that the nasal tip is particularly satisfactory from an aesthetic viewpoint when its contour is horizontally oriented in the frontal view. A position in which the 2 cephalic margins of the lateral crura form an angle of approximately 90° is considered ideal in this respect. Another surgical objective is to place the caudal margin of the lateral crus at the same level as the cephalic margin. When necessary, the repositioning of the lateral crura must obviously form part of a broader surgical plan that also involves correction of the projection and rotation of the tip.TechniqueOpen access is performed to expose the alar cartilages and nasal dorsum. To this end, an inverted V-shaped columellar incision is made along with 2 marginal incisions of the nasal vestibule. The marginal incisions are made in a more caudal position with respect to the lower margin of the lateral crura in order to accommodate the repositioned cartilages. Careful detachment and isolation of the tip reveal the cephalic malposition of the lateral crura and the abnormal relationship between their cephalic and caudal margins, with the latter lying beneath the former (Figure 1).Figure 1. Intraoperative view of malpositioning of lateral crura. A, Cephalically positioned lateral crura. B, Caudal margin of lateral crura placed below cephalic margin.Reshaping of the nasal tip generally requires the conservative excision of a strip of cartilage from the cephalic portion of the lateral crura, leaving at least 6 to 7 mm of residual cartilage. This step is followed immediately by a stairstep incision in the posterior third of the posterior portion of the lateral crura, leaving the skin of the nasal vestibule beneath intact (Figure 2) and yielding 2 segments of lateral crural cartilage on both sides: 1 anterior segment, which is secured to the domus, and 1 posterior segment, which is secured to the pyriform aperture. The cartilage is completely detached from the skin beneath as far as the domus, starting from the incision and working outward from the rear, in order to completely free an anterior flap of the lateral crura (Figure 3). The posterior segment of the lateral crura must also be detached for a few millimeters working backward.Figure 2. Lateral crural stairstep technique. A, Schematic drawing of stairstep incision. B, Intraoperative view of incision.Figure 3. Detachment of anterior segments of lateral crura from skin of nasal vestibule beneath as far as the domus.Then, the spatial repositioning of the lateral crura can be undertaken. There are 5 surgical options, depending on the case in question. First, when a parenthesis deformity with no other impairments of the nasal tip is involved, the lateral crura are moved downward and the upper step is secured on top of the lower step (Figure 4A). Second, when there is the lateral crura with overprojection and ptosis of the tip, the downward movement of the anterior flap is combined with overlapping and sliding backward on the posterior flap to attain the desired degree of rotation and projection (Figure 4B). Third, when the malposition of the lateral crura is accompanied by marked overprojection of the nasal tip, it is also possible to use the medial crural overlay technique,4 in which both the medial crura are sectioned and secured in an overlapping position (Figure 4C). Fourth, even when there is no malposition but there is overprojection of the tip along with evident overrotation, combining a medial crural overlay with the lateral crural stairstep technique can prove to be very useful. Reduction of the projection and rotation of the tip can be enhanced by shifting the anterior flap forward with no overlapping and by simply suturing the margins of the 2 segments (Figure 4D). In all of the above-mentioned surgical options, the cartilaginous segments are secured to one another by means of sutures with 6.0 nylon, while the skin beneath is secured to the lateral crura by means of mattress sutures of 5.0 polyglactin 910 (Vicryl) with the knots on top (Figure 5).Figure 4. Surgical options of the lateral crural stairstep technique. A, Correction of a pure parenthesis deformity. B, Correction of malposition of lateral crura combined with overprojection and ptosis of tip. C, Correction of malposition of lateral crura combined with marked overprojection of tip. D, Correction of overprojection and overrotation of tip with no malposition of lateral crura.Figure 5. Suturing of cartilage segments with 6.0 nylon.The caudal margin of the domus should also be slightly higher than the cephalic margin. This ideal position of the alar cartilages can be obtained by downward and outward rotation of the lateral crura with a cephalic-posterior interdomal suture as a fixed point of reference (Figure 6). After suturing, scissors can be used to remove any surplus material, protrusions, or asymmetries in the lower margin of the lateral crura (Figure 7). On the contrary, downward protrusion of the lateral crura can prove useful in revision rhinoplasty to eliminate pinching of the alar margin. This situation constitutes the fifth surgical option (Figure 8). The medial crura are normally strengthened by means of a columellar strut taken from the nasal septum or by using the tongue-in-groove technique.5 In the latter case, the caudal septum is inserted and secured between the medial crura, which has the further effect of correcting droopy nose with excessive columellar show. A transdomal suture often proves useful at the end of the procedure to improve nasal tip definition. The marginal incisions are then sutured with 5.0 polyglactin 910 and the columellar incision with 6.0 nylon. The procedure ends with the insertion of an anterior nasal tampon, which is removed after 24 to 48 hours, and the application of an external splint.Figure 6. The caudal margin of the domus is slightly higher than the cephalic margin.Figure 7. Removal of protruding cartilage from the lower margin of lateral crura.Figure 8. Patient who underwent a previous rhinoplasty with nasal wings pinched. Correction was performed via the lateral crural stairstep technique without removal of the lower margin of the lateral crura (fifth surgical option of the technique]). A and C, Preoperative views; B and D, postoperative views after 13 months.The lateral crural stairstep technique can be carried out alone or combined with other complex techniques. In any case, the reshaping of the tip should be left until last to avoid the risk of disrupting the delicate relationship between the juxtaposed cartilage segments with other maneuvers. The preoperative and postoperative photographs of a typical case illustrate the correction of a parenthesis deformity of the tip along with hump excision and the correction of crooked nose by means of the septal crossbar graft technique (Figure 9).6,7 The intraoperative photographs of the case in question are those presented previously in the description of the surgical procedure. To demonstrate the versatility of the lateral crural stairstep technique, each of the other situations in which it can be used is illustrated with long-term follow-up photographs taken 1 year after surgery (Figures 10, 11, and 12).Figure 9. Patient who presented with dorsal hump, crooked nose, and cephalic malposition of lateral crura with overprojection and ptosis of the tip. Correction was performed via hump excision, septal crossbar graft technique, and lateral crural stairstep technique. Anterior segments of lateral crura were moved down and back to overlap with posterior segments. A and C, Preoperative views; B and D, postoperative views after 1 year.Figure 10. Patient who presented with malposition of the lateral crura with overprojection and ptosis of the tip (correction performed with surgical option in Figure 4B). A and C, Preoperative views; B and D, postoperative views.Figure 11. Patient who presented with malposition of the lateral crura with overprojection of the tip (correction performed with surgical option in Figure 4C). A and C, Preoperative views; B and D, postoperative views.Figure 12. Patient who underwent a previous rhinoplasty with overprojection and overrotation of the tip (correction performed with surgical option in Figure 4D). A and C, Preoperative views; B and D, postoperative views.ResultsBetween January 2005 and March 2006, a total of 22 patients (14 men and 8 women) underwent rhinoplasty via the lateral crural stairstep technique. The patients' ages ranged from 22 to 60 years (average age, 37 years). While the parenthesis deformity alone was present in 5 cases, it was also found along with other deformities of the nasal tip, being combined with overprojection and ptosis in 7 cases and marked overprojection in 4 cases. Pinching of the nasal wings was present in 3 cases as a result of previous rhinoplasty, and 3 patients had overprojection along with overrotation as a result of iatrogenous factors in 2 cases. Other deformities regarding both the middle nasal vault and the upper third were also present in 15 cases: osteocartilaginous hump in 10 cases, deviation of the nasal pyramid in 5 cases, and both in 7 cases. Other techniques were also used to correct the deformities in these cases, but there were no negative effects due to the use of the lateral crural stairstep technique. The only difficulty in the execution of this technique arose during detachment of the lateral crura, when laceration of the underlying cutaneous lining occurred more than once. There were no postoperative complications, however, and the risk of laceration could be reduced by administering an abundant dose of local anesthetic plus a vasoconstrictor shortly before detachment. The follow-up period ranged from 12 to 14 months. A substantial improvement in the shape and spatial orientation of the lateral crura, as well as balanced values for the parameters of rotation and projection, was observed in all cases. These positive results were noted not only by the surgical team but also by the other physicians involved in the subsequent checks and above all by the patients themselves. Sugical revision was required in only 1 case because of a supratip deformity of cicatricial origin and was not associated in any way with the use of the lateral crural stairstep technique.CommentThe Anderson tripod theory represents a milestone in the history of surgery on the nasal tip.8,9 It describes the joined medial crura as 1 leg and the lateral crura as the other 2 legs. The variations in the length of the 3 elements produce modifications in the rotation and projection of the tip, leading to many of the deformities presented by patients. In this theoretical model, however, the lateral crura are represented as straight segments, while they are actually flat anatomical structures with variable 3-dimensional orientation in space. The tripod concept therefore fails to cover all the situations involving malposition of the lateral crura with or without impairment of the projection and rotation of the nasal tip. At the same time, cephalic positioning of the lateral crura and vertical orientation of their anatomical plane also lead to major aesthetic and functional problems in the presence of correct tip projection and rotation.Either alone or combined with medial crural overlay, the lateral crural overlay technique proposed by Kridel and Konior10 in 1991 offers an excellent way of resolving all the pathologic variants regarding tip projection and rotation with no weakening of the anatomical structures. The sliding, overlapping, and suturing of the segments make it possible to adjust these 2 important parameters, while preserving the continuity of the cartilaginous arch. The use of a step-shaped rather than vertical section of the lateral crura makes it also possible to adopt the technique in cases involving the malposition of alar cartilages in that the anterior segment of the lateral crura can be detached and sutured in a lower position while being kept firmly secured to the posterior segment. Other surgical procedures used for the same purpose of correcting parenthesis deformity involve detachment of the lateral crus as a whole, removal from the pyriform aperture, and repositioning at a lower level. Given the absence of posterior anchorage in these procedures, however, it proves difficult to obtain both sufficient stability and symmetry on the 2 sides owing to the lack of any point of reference. In the lateral crural stairstep technique, the presence of the small posterior segment of lateral crus left in its original position, despite its lack of aesthetic importance, makes it possible to change the position of the tip with the certainty of obtaining symmetry on both sides. In point of fact, the stepped shape of the 2 cartilaginous margins brought together gives an immediate visual idea of the measurements with no need for the use of sophisticated instruments.In conclusion, the technique is capable of modifying 1, 2, or all 3 parameters of the nasal tip (projection, rotation, and position), as required, at the same time and with great precision. Also, the downward rotation of the lateral crura makes more conservative reshaping of the nasal tip possible, with no need for the removal of a substantial strip from the cephalic portion of the cartilages. Moreover, the overlapping of the 2 cartilage segments for quite a long stretch provides additional support for the alar cartilages and flattens the lateral crura to create an unquestionably better aesthetic effect.References1. Friedman O, Akcam T, Cook T. Reconstructive rhinoplasty: the 3-dimensional nasal tip. Arch Facial Plast Surg. 2006;8(3):195-201.16702532 Link, Google Scholar2. Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applicatons in rhinoplasty. Plast Reconstr Surg. 1997;99(4):943-952.9091939 Crossref, Medline, Google Scholar3. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8(3):156-185.16702528 Link, Google Scholar4. Soliemanzadeh P, Kridel RHW. Nasal tip overprojection: algorithm of surgical deprojection techniques and introduction of medial crural overlay. Arch Facial Plast Surg. 2005;7(6):374-380.16301456 Abstract, Google Scholar5. Kridel RW, Scott BA, Foda HM. The tongue-in-groove technique in septorhinoplasty: a 10-year experience. Arch Facial Plast Surg. 1999;1(4):246-256.10937111 Link, Google Scholar6. Boccieri A, Pascali M. Septal crossbar graft for the correction of the crooked nose. Plast Reconstr Surg. 2003;111(2):629-638.12560684 Crossref, Medline, Google Scholar7. Boccieri A. Evolution of the septal crossbar graft technique. Facial Plast Surg. 2006;22(4):255-265.17131268 Medline, Google Scholar8. Anderson JR. The dynamic of rhinoplasty. In: Bustamant GA, ed. Proceedings of the Ninth International Congress of Otorhinolaryngology, Mexico City, August 10-14, 1969. Amsterdam, the Netherlands: Excepta Medica; 1970: ser 206 Google Scholar9. Anderson JR. A reasoned approach to nasal base surgery. Arch Otolaryngol. 1994;110(6):349-358.6721774 Medline, Google Scholar10. Kridel RW, Konior RJ. Controlled nasal tip rotation via the lateral crural overlay technique. Arch Otolaryngol Head Neck Surg. 1991;117(4):411-415.2007012 Crossref, Medline, Google ScholarFiguresReferencesRelatedDetailsCited byEvaluation of Lateral Crural Steal in Nasal Tip Surgery Lucas G. Patrocínio, Tomas G. Patrocínio, Daniel M. Barreto, Yasin S. Subhan, and José A. Patrocínio20 November 2014 | JAMA Facial Plastic Surgery, Vol. 16, No. 6Lateral Crural Setback With Cephalic Turn-in Flap A Method to Treat the Drooping Nose Amir A. Sazgar1 November 2010 | Archives of Facial Plastic Surgery, Vol. 12, No. 6In Praise of Rhinoplasty Wayne F. Larrabee1 November 2010 | Archives of Facial Plastic Surgery, Vol. 12, No. 6Has the Pendulum Swung Too Far? Trends in the Teaching of Endonasal Rhinoplasty Steven Dayan and Raj Kanodia2 November 2009 | Archives of Facial Plastic Surgery, Vol. 11, No. 6The Legacy of Jack Anderson, MD Ali Sepehr and Peter A. Adamson2 November 2009 | Archives of Facial Plastic Surgery, Vol. 11, No. 6Measuring Outcomes in Nasal Surgery Realities and Possibilities John S. Rhee2 November 2009 | Archives of Facial Plastic Surgery, Vol. 11, No. 6 Volume 10Issue 1Jan 2008 InformationCopyright 2008 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.To cite this article:Armando Boccieri and Giuseppe Raimondi.The Lateral Crural Stairstep Technique.Archives of Facial Plastic Surgery.Jan 2008.56-64.http://doi.org/10.1001/archfacial.2007.7Published in Volume: 10 Issue 1: January 1, 2008PDF download

Sir: The appearance of irregularity in the nasal contour some time after revision rhinoplasty is reported quite frequently, even by experienced surgeons. Thin skin, multiple grafts in contact with one another, angular cartilaginous margins, and scar tissue are all factors conducive to this situation. The perichondrium can easily be harvested from the concha, with no need for additional surgical approaches because the use of auricular cartilage is in any case very frequent in secondary rhinoplasties. After suitable preparation, this tissue is positioned on top of the grafts to fill the gaps, cushion the surface of the grafts, and separate scar adhesions between the skin and the layers beneath (Fig. 1).Fig. 1.: A graft of perichondrium is stretched over and secured to cartilaginous grafts (onlay and alar batten) to make the contours smooth and disguise tip grafts.Kamer published a description of the use of this type of graft in the correction of bossae to smooth out the cartilaginous contour if the sharp edges of cartilage remain apparent.1 Attention has recently been drawn to its effectiveness in revision rhinoplasties to prevent the graft showing after long-term follow-up and to ensure a smooth contour in cases involving a combination of shield graft and lateral crural graft.2,3 This study examines the use of perichondrium grafts on 45 patients (32 women and 13 men) subjected to revision rhinoplasty between January of 2001 and March of 2004. Improvement of the preoperative nasal deformity was obtained in all cases. Follow-up ranged from 20 to 32 months (median, 26 months). There were no instances of infection, movement, or substantial absorption of the grafts. A sample of 20 patients affected by rhinoplastic sequelae and subjected to revision rhinoplasty without use of the perichondrium graft was used as a control group to compare the results obtained. The results achieved in patients subjected to perichondrium grafts proved superior also over a span of 32 months, with regular and uniform nasal contours. Only one patient, affected by cleft-lip nasal deformity, required further revision surgery to correct asymmetry of the tip caused by the use of an insufficiently large cartilage graft on one side. Carried out 9 months after the previous operation, this revision made it possible to ascertain the stability of the attachment of the perichondrium to the structures in question and execute a biopsy of the perichondrial tissue grafted together with a fragment of the cartilage beneath (Fig. 2).Fig. 2.: Histologic specimen of perichondrium grafted 9 months earlier, where it is possible to see in the lower central area cartilage surrounded by dense connective tissue related to the perichondrium with the presence of granulation tissue and macrophages containing lipidic material at the edges.The histologic results of the biopsy of the perichondrial tissue grafted 9 months earlier, comparison with the histologic condition of the freshly harvested perichondrium, and immunohistochemical tests have made it possible to formulate some important observations. Over time, the grafted perichondrium displays neither encapsulation nor the presence of reactions triggered by an extraneous body. The graft is not reabsorbed but retains its histologic individuality. An increase in dense and sclerosed perichondrial connective tissue can be detected adjacent to the cartilage. It can therefore be suggested that the positioning of the graft causes an initial inflammatory response on the lower side, the effect of which over time is to incorporate the perichondrium and cement it to the cartilaginous surface, smoothing out the rough edges below. Armando Boccieri, M.D. Department of Maxillo-Facial Surgery S. Camillo Hospital V. le U. Tupini 133 00144 Rome, Italy [email protected]

Graft selection remains a problem in nasal reconstruction, where the use of autologous cartilage still provides the best resistance to infection and a low degree of resorption. As the nasal septum is often absent or insufficient in such patients, the auricular concha offers a valid alternative. A group of 53 patients suffering from developmental iatrogenic and post-traumatic nasal pathologies were treated surgically by means of conchal grafts. Detailed examination of the anatomical defects presented by the patients made it possible to plan the removal of grafts from the area of the auricular concha with great precision. Guidelines were developed for the areas of the cymba concha and cavum concha to be used as sources for some types of commonly used graft. The technique described made it possible to restore the anatomically deficient structures with satisfactory aesthetic and reconstructive results. The use of cartilage grafts also addressed functional breathing problems. The auricular concha is easy to shape and can provide grafts to reconstruct the various anatomical components of the nasal pyramid. To this end, it proves very useful to save as much cartilage as possible and to pinpoint affinities between some areas of the concha and the structures to be reconstructed.

This article reviews the case of a 29-year-old woman who underwent revision rhinoplasties. Preoperative photographs and postoperative photographs 1 year after surgery are included.

The septal crossbar graft is a surgical technique used to correct crooked nose and solve the associated functional and aesthetic problems. Described for the first time in 2003, it combines staggered septal incisions with a spreader graft in the dorsal septum on the concave side of the deviation. The method has proved particularly useful in straightening the septum and ensuring postoperative results of lasting stability. Clinical experience over the last few years and the identification of some snags in the procedure have prompted modifications of the technique that should be regarded essentially as evolutionary stages. This article provides a detailed description of all the surgical phases of the technique in the light of these developments and discusses its strengths with respect to the specific problems of crooked nose. Attention is drawn in this connection to both the functional effect on the internal nasal valve and the aesthetic effect of reshaping the upper lateral cartilage.