Fortunately, traumatic total amputations of the nose are rare, especially in children. Their reconstructions generally require several operative steps, most often associating cartilaginous grafts (rib and/or concha), a free radial antebrachial flap for mucosal reconstruction and a frontal flap for the skin covering. These are therefore long and complex procedures requiring a trained surgical team and maximum patient adherence to their treatment plan. The clinical case described is that of an 11-year-old child presenting a sub-total amputation of the nose and having undergone reconstruction with skin expansion of the frontal flap due to a horizontal frontal scar of unknown origin and a particularly low hair implantation.

As a very challenging surgery, primary rhinoplasty can lead to secondary. After a primary, patient's concerns can sometimes be pretty easy to fix (remaining bump), but may some other request long and very difficult surgeries (short nose). This article describes the most common reasons of secondary rhinoplasties and provides, for each of them, a surgical treatment.

Background Defects involving several aesthetic subunits (ASUs) or lying at the junction of an ASU are challenging and require a complex reconstruction. This study aimed to describe the hemi-tip as a new ASU. Material and methods We conducted a retrospective study including patients who underwent a nasal reconstruction for lower nasal pyramid defects according to our modified ASU principle. Patients who suffered from a subtotal alar defect, which also involved <50% of the tip, were reconstructed after excising the remaining tissue of the hemi-tip subunit. An aesthetic evaluation was performed using a patient satisfaction scale and by independent raters. Results From 2010 to 2014, 21 patients underwent a lower hemi-nose reconstruction. All patients had a full-thickness defect and underwent a reconstruction of the three layers of the nose. Sixty-four percent of our patients were very satisfied, 26% were satisfied, and only 10% were unsatisfied with their nasal tip appearance, with a mean score of 4.4/5. The nasal tip was also rated by independent raters with a mean score of 4.1/5. Discussion Our results and experience showed that a midline scar between the two hemi-tips is inconspicuous. The majority of the defects involving only one side of the tip would benefit from the hemi-tip ASU reconstruction. Conclusion We have modified the number of ASUs by considering the hemi-tip as a proper subunit.

The sub mental island flap is a precious tool in reconstructive surgery. It was described by Martin in 1993, inspired by platysma flaps. In our days, we can find many reliable techniques for this procedure. We reviewed the main studies of the literature that described a total of 528 patients. The rate of partial necrosis was 5.1%, complete necrosis 1.7%, and reversible lesions of the marginal mandibular branch of the facial nerve 1.1%. His versatility makes this flap appropriate for the reconstruction of every part of the face: cheeks, nose, forehead, moustache, beard, and hairs. It can also be used de-epidermised with very good results, for the reconstruction of the buccal cavity, the tongue, the roof of the mouth, the larynx, and the proximal part of the esophagus. The SMAP (Submentalis Artery Perforator flap) is an alternative flap that provides even better cosmetic results. The development of indocyanine green and infrared cameras will allow in a close future to decrease the postoperative complications. (C) 2014 Elsevier Masson SAS. All rights reserved.

Le lambeau sous-mental est un outil précieux dans la chirurgie reconstructrice de la face. Inspiré des lambeaux platysmaux, il est imaginé par Dominique Martin en 1990. Plusieurs travaux ont permis de fiabiliser son prélèvement et d’agrandir son arc de rotation par des techniques d’allongement du pédicule comme l’YV veineux, le prélèvement rétrograde ou la forme hybride. La synthèse des principales séries publiées retrouve 528 patients traités par lambeaux avec un taux de nécrose partielle de 5,1 %, de nécrose totale de 1,7 % et de lésions réversibles de la branche marginale mandibulaire du nerf facial de 1,1 %. Sa plasticité a permis de nombreuses utilisations en comblement des pertes de substances de la face comme la joue, la tempe, le nez, la barbe, la moustache, la patte des cheveux chez l’homme, et l’orbite. Il est utilisé désépidermisé en comblement des parties molles de la face, et pour la reconstruction de l’ensemble des parois de la cavité buccale, la langue, le palais mou, le larynx et même le tiers proximal de l’œsophage avec d’excellents résultats fonctionnels. La variante cutanée perforante ou Submentalis artery perforator flap (SMAP), prélevée au-dessus du muscle platysma, permet un modelage encore plus esthétique. Le développement du vert d’indocyanine et de la caméra infra-rouge permettra dans un avenir proche de visualiser l’étendue de la vascularisation de la palette cutanée pendant l’intervention et diminuer les nécroses post-opératoires.

Nowadays, cartilage grafts are widely used in secondary as well as primary rhinoplasty. Even if their fixation is often easier and more precise using an open approach, most of them can also be positioned with a close approach. In this article, the authors describe various cartilage donor sites. For each of them, they describe benefits, inconveniences, harvesting techniques and preferred indications. Cartilage can be harvested on the septum, ear and ribs. For the authors, septal cartilage is often the best material but can be insufficient or totally missing (especially in secondary rhinoplasty). In such cases, concha cartilage is a good material for tip and alar grafts because of its pliability and convexity whereas rib cartilage, which is stiffer and thicker, will provide good supporting grafts. Described more recently, diced cartilage wrapped in fascia (DCF) can be a very good option for dorsal onlay graft, avoiding irregularities of conchal cartilage and risk of rib cartilage's twisting. (C) 2014 Elsevier Masson SAS. All rights reserved.

In the first step of rhinoplasty, the surgical approach will expose through different types of incisions and dissection planes the osteocartilaginous framework of the nasal pyramid prior to performing actions to reduce or increase the latter. This exposure can be performed by a closed approach or by an external approach--the choice depends on the type of nose and the habits of the surgeon. Far from being opposites, closed and external approaches are complementary and should be known and mastered by surgeons performing rhinoplasty.

Même si leur intérêt était connu depuis longtemps, la démocratisation de la voie externe a permis le développement important des techniques de sutures en rhinoplastie ces vingt dernières années. Aujourd’hui, elles sont très couramment utilisées et constituent une technique fiable pour contrôler la forme et la position des cartilages alaires. Les auteurs dressent la liste des différents types de sutures dont dispose le chirurgien. Pour chacune d’elle, il décrit sa réalisation et les effets que celle-ci entraînera sur la forme de la pointe du nez.

The decision to perform nasal resection follows a comprehensive analysis of the aesthetic objective depending on the anatomic and artistic criteria. Fear of leaving visible scars leads many surgeons to hesitate vis-à-vis the indications. However, this surgical technique can be very useful during rhinoplasty. The patient should always be informed preoperatively of the possibility of cutaneous resection of the nostrils and the type of scar than can ensue. It is important to know the foreseeable elements of nasal resection in order to provide a more systematic approach to routine rhinoplasty.

Une gêne respiratoire nasale est souvent rapportée à une déviation septale ou à une hypertrophie des cornets inférieurs. Le rôle des valves externes et internes est parfois peu connu des chirurgiens alors qu’il est essentiel dans la perméabilité nasale. En outre, le bon fonctionnement de ces valves est généralement en relation directe avec la morphologie externe du tiers moyen du nez et des parois alaires. À ce titre, un examen préopératoire soigneux, la recherche systématique de facteurs prédisposant à un collapsus et une chirurgie conservatrice permettront souvent d’éviter les problèmes esthétiques et fonctionnels de ces deux régions délicates.

La demande de rhinoplastie secondaire peut correspondre à un réel défaut qu’il faut corriger mais également parfois à un résultat tout à fait correct mais mal accepté par le patient. C’est d’un examen soigneux et d’une enquête clinique et paraclinique que découlera la prise en charge. Du simple conseil de retour vers le chirurgien initial jusqu’à la reprise complexe d’un nez cicatriciel dont la structure ostéocartilagineuse a été très altérée, toutes les situations peuvent se rencontrer. Les auteurs analysent les situations les plus fréquentes et proposent des principes de prise en charge conformes à leur expérience. Les techniques utilisées en rhinoplastie secondaire ne sont pas différentes de celles de la chirurgie primaire mais leur mise en œuvre est particulière : difficultés de dissection et d’exposition, bilan anatomoclinique qui ne sera complet qu’en peropératoire, couverture muqueuse quelques fois aléatoire. Ces conditions particulières associées quelques fois à l’impossibilité de garantir au patient d’obtenir exactement le résultat qu’il attend font à la fois l’intérêt et la difficulté de la rhinoplastie secondaire.

L’étude préopératoire en rhinoplastie consiste à analyser les caractéristiques anatomiques et fonctionnelles individuelles sans perdre de vue la demande initiale du patient qu’il faudra corriger en priorité. L’examen est avant tout clinique mais utilise également des photographies préopératoires prises sous des angles précis. Le dépistage des troubles fonctionnels ou des pathologies générales associées permet de réduire le risque de complications. Une fois tous ces éléments pris en compte, le chirurgien peut établir un plan de rhinoplastie qu’il faudra ensuite expliquer au patient pour obtenir sa compréhension et son adhésion.

To many surgeons, nasal airway obstruction is synonymous with either septal deviation or inferior turbinate hypertrophy. The role of internal and external nasal valves is often less known by surgeons even if it is crucial in nasal breathing and strongly interrelated with esthetic of the middle third of the nose and alar wall. Therefore, precise examination of the two valves and conservative surgery should help to avoid many functional and esthetic problems.

Thorough knowledge of the anatomy of the nose is an essential prerequisite for preoperative analysis and the understanding of surgical techniques. Like a tent supported by its frame, the nose is an osteo-chondral structure covered by a peri-chondroperiosteal envelope, muscle and cutaneous covering tissues. For didactic reasons, we have chosen to treat this chapter in the form of comments from eight key configurations that the surgeon should acquire before performing rhinoplasty. (C) 2014 Elsevier Masson SAS. All rights reserved.

Qu’elles soient paramédianes, supérieures ou latérales, effectuées par voie endonasale ou percutanée, les ostéotomies ont pour objectif de modifier la forme de la partie osseuse du nez. Loin d’être systématiques, elles peuvent être utilisées seules ou en association les unes aux autres. Leurs principales indications sont la correction d’une asymétrie de la voûte osseuse, la réduction d’une voûte large et la fermeture d’un toit ouvert après résection d’une bosse ostéocartilagineuse importante. Dans tous les cas, elles doivent être réalisées avec la plus grande prudence afin d’éviter toute complication et après analyse précise du nez pour ne pas créer de gêne obstructive ou de déformation de type V inversé, marche d’escalier, nez pincés ou ensellure.

Overprojected tip is a pretty usual request not easy to manage. Preop analysis is crucial in order to evaluate tip support and skin thickness and ability to retract. For example, if the skin is very thick and has poor chance to retract, the surgeon should be very careful in the tip projection decreasing to avoid a skin pollybeak deformity. In such cases, he has to analyze the facial proportions, especially other areas projection (radix, dorsum and chin) and think about augmenting them to balance the profile rather than decreasing tip projection. Correction should always be conducted incrementally, starting with weakening the tip support mechanisms and, only if necessary, continue with alar cartilage interruption. This can be performed on many areas (lateral cruras, domes, medial cruras) and with several techniques (resection or interruption + overlapping). (C) 2014 Elsevier Masson SAS. All rights reserved.

Osteotomies are performed to modify the shape of the bony part of the nose, therefore they should not be done systematically. Main indications are correction of deviated nose, narrowing of bony vault and roofing of an open roof after important hump resection. The nose should be very precisely analyzed before osteotomies if the surgeon doesn't want to create deformities such as step, inverted V, pinched nose or saddle nose. When too narrowed, bones can also block the airway and lead to functional problems.

Suture techniques are widely used and can be very useful and efficient to support the nasal tip and correct its deformities. Nevertheless, they are so powerful that they have to be performed very precisely if the surgeon does not want to create cosmetics as well as functional problems. The authors describe the main tip sutures and their effects, expected or not. (C) 2014 Elsevier Masson SAS. All rights reserved.

La décision de réaliser une résection narinaire passe par une analyse globale de l’objectif esthétique reposant sur des critères anatomiques et artistiques. La crainte de la visibilité des cicatrices conduit de nombreux chirurgiens à hésiter sur ces indications, pourtant ce geste chirurgical peut être d’une grande utilité au cours de la rhinoplastie. Le patient devra toujours être prévenu en préopératoire de la possibilité d’une résection cutanée au niveau des ailes narinaires ainsi que du type de cicatrice qui en découle. Il est important de connaître les éléments prédictifs d’une résection narinaire pour permettre une approche plus systématisée de la rhinoplastie au quotidien.

Secondary rhinoplasty is very usual. Some patients are not satisfied by the previous surgery because the result is poor with obvious defaults but, sometimes, the result is good but the patient expects perfection. These two different situations will not lead to the same answer from the surgeon. Techniques of secondary rhinoplasty are the same than primary, but are often more difficult to perform because of scar tissue, retraction and loss of lining. The authors analyse the more frequent deformities in secondary rhinoplasty and the way they fix them.