Structural Rhinoplasty is a term use by rhinoplastic surgeons wherein the existing structures are reconstructed and strengthened for functional and aesthetic improvement of the nose. The function refers mainly to breathing by correcting septal deviation and enlarging the internal valves.1

The usual surgical method is open rhinoplasty approach and all anatomical structures are analyzed. The central septal cartilage is removed while the remaining dorsal and caudal strut are reconstructed for better breathing and tip support.2 The general concept is to alter the length and height of the existing dorsal and caudal strut by restructuring with the use of the central harvested cartilage. Cartilages used for strengthening the struts are called structural grafts while cartilages used for tip reshaping and projection are called contour grafts.3

Structural grafts commonly include the columellar strut graft, septal extension graft (SEG), spreader graft or extended spreader graft (ESG).1 The columellar strut and SEG are used for lower cartilage and tip support. The spreader graft is used for strengthening the dorsal strut and enlarging the internal valve. The ESG is a spreader graft that is extended beyond the anterior angle of the septum for support of lower cartilage and tip. Among the structural grafts for lower cartilage tip support it is the Septal Extension Graft (SEG) that gives the best longevity.4 The SEG is either placed side-to-side to the caudal strut or end-to-end supported by bilateral extended spreader graft (ESG). (Figures 1 & 2) Sometimes, a combination of ESG with SEG is needed to correct weakness of the struts. (Figure 3) Contour grafts are usually the dorsal graft and tip grafts. (Figure 4)

Because Asian (specifically South East Asian) noses are usually small, the harvested septum is often small and soft.3,4 Occasionally, the septum may look strong but upon harvest the dorsal and caudal struts weaken. Additional cartilage grafts are usually needed either from the auricle or from the rib. Auricular cartilage is too soft as support graft while the rib cartilage is strong because of its resemblance to septum in its histology. Autologous rib rhinoplasty is not only tedious and invasive but also more expensive which most patients do not prefer. Because of the paucity of septum, there are many substitute commercial materials in the market which can simulate the strength of septal cartilage as support graft. These can be homologous processed human rib cartilage, or alloplastic non-absorbable porous polyethylene. These materials are prone to long term complications e.g. warping, fracture, infection, resorption and extrusion.5,6 Scientists and bioengineers recently developed polycaprolactone (PCL) which is a new synthetic absorbable porous material. It is marketed as a better material because not only it gives support but it also serves as a scaffold for tissue regeneration.7-9

Polycaprolactone (PCL) is an absorbable material used in craniomaxillofacial surgery as a scaffold for defects.10 It is absorbed completely in 2 years. It is also a material used as threads in facial rejuvenation.11-13 Recently, PCL has been fashioned into mesh for use in septoplasty and rhinoplasty as implants and support.14,15 Its use is mainly as a scaffold for tissue regeneration and support. It has been shown in studies that osteoblasts, chondroblasts and mesenchymal tissues grow into its pores.10, 15 It comes in various shapes and sizes. The ideal ones for use in nasal surgery are the 10 mm x 30-40 mm mesh plate with thickness variety of 0.8-1.2 mm. (Figure 5)

Polycaprolactone is not used routinely; it is still best to use all autologous tissues. The indication of the use of PCL depends on the structure of the nose (mainly the septum). It is best for use in cases of small septum with inadequate septal material for correction of deviation. It is also best for use in cases of weak septum or weak dorsal/ caudal struts after septal harvest to correct any possibility of collapse. Moreover, PCL is not advisable in severe contracted nose because forces of healing may lead to wound dehiscence, extrusion and infection. Extrusion and infection may also happen while PCL is still not completely absorbed in 2 years. 

Since PCL is noted to lose its strength but provide well as a template for tissue regeneration, it is recommended to cover the PCL with septal or conchal cartilages whenever possible for 2 reasons: firstly, for protection against mucosal erosion; and secondly, as cartilage regeneration template for future support. (Figure 6). The decision to use PCL is made intraoperatively. The PCL mesh is fashioned into either an end-to-end SEG or ESG; both techniques of grafting are covered majority with cartilages. Following is the algorithm showing the indications when to use PCL after open rhinoplasty approach and assessment of the strength of the septum:

There are times wherein minimal surgery is needed for tip projection. Since Asian noses have weak medial crura with heavy skin and soft tissue envelope, PCL can be used just as a columellar strut - either floating or fixed to the posterior caudal septum. Fixing to the posterior caudal septum functions similar to a SEG too. However, these techniques may be unstable. (Figures 12 & 13)

Polycaprolactone was commercially available locally in the latter part of 2018. From August 2018 to March 2020, I used PCL in 213 (40.7%) out of 523 cases of septoplasty for structural rhinoplasty for various indications. All outcomes were followed up through calls and/or texts and all results were good with all patients satisfied with their results as of this writing, except for two. One patient developed post-operative deviation of the SEG after a week; the etiology was due to the improper choice of PCL strength. Revision surgery was done with replacement by a thicker PCL. Another patient developed infection after 4 months. Revision surgery involved removal of PCL and placement of columellar strut for support. This initial experience with the use of PCL is promising but it is too early to conclude. Long term follow-up should be done to see changes in structure when the PCL is totally absorbed.

In summary, PCL is a strong absorbable tissue template mesh in septoplasty and rhinoplasty. It is gradually absorbed within 2 yrs. While it is in its early stage as a mesh graft, it gives strength. However, as it is slowly absorbed, it imbibes the surrounding tissue cells for regeneration for future strength. It is highly recommended to cover the PCL with cartilages to prevent erosion to surrounding mucosa. Aside from protection of the PCL against erosion and extrusion, the cartilage also gives the future strength as chondrocytes grow into the PCL mesh.

Deviated nose deformities have always been a surgical challenge, and it is essential to achieve both functional and esthetic improvements. Various techniques have evolved over time to correct deviated noses but no one method applies in all cases. Successful correction requires a complete understanding of the various surgical techniques and concepts, including the three-dimensional nasal structure and the time-related changes to surgically-treated noses.
Congenital Abnormalities ; Methods ; Nasal Septum ; Nose Deformities, Acquired ; Nose* ; Rhinoplasty

Humans ; Nasal Septum ; surgery ; Nose Deformities, Acquired ; surgery ; Sinusitis ; surgery

Endoscopes ; Humans ; Nasal Septum ; surgery ; Nose Deformities, Acquired ; surgery

Cosmetically to correct large, thick and flaring ala, Weir method have been frequently used. But after excessive Weir excision, it causes tightened distal nose, lowered nasal tip, and unnatural shape of ala. A 32-years-old female patient suffered from the marked tightness of distal nose, lowered height of nasal tip, and mild dyspnea after Wier excision 1 year ago. She showed unnatural alar base shape with blunting of alar-facial groove angle up to 110 degree, and it rapidly slanted to the nasal tip. The incision was made along the previous operative scars at alar base, and release of tension were done. There was a 7mm gap in each side of both alar bases. The two wedge shaped composite grafts from the left helical rim were obtained, and insetted to the alar base gaps. Immediately after operation, she showed relief of dyspnea and tightness of nasal tip, and improved shape of distal nose. The 3 months postoperatively , mild hyperpigmentation of the grafted sites were noticed. The overall results were excellent. To correct the deformed ala and unnatural distal nose shape after excessive alar reduction using Wier excision, we present a technique of the composite auricular chondrocutaneous grafts at alar base.
Cicatrix ; Cosmetics ; Dyspnea ; Female ; Humans ; Hyperpigmentation ; Nose ; Nose Deformities, Acquired ; Succinates ; Transplants

OBJECTIVETo compare the efficacy of two surgical techniques for controllong nasal width after Le Fort I osteotomy.

METHODSFifty-five patients who received the Le Fort I osteotomy have been included in this study. They were randomly divided into 2 groups. The experimental group received extraoral ABS, and the control group received traditional intraoral ABS. 3D photos of the patient's face were taken before operation and at postoperative 3 months. Alar width was measured on the 3D photos. Data was reported as means and standard deviations, and statistic analysis was done by using student t test.

RESULTSCompared with presurgical data, G. lat-G. lat increased by (2.66 +/- 1.47) mm, Al-Al increased by (2.20 +/- 1.22) mm and Sbal-Sbal increased by (1.30 +/- 1.33) mm in experimental group. G. lat-G. lat increased by (1.38 +/- 1.29) mm, Al-Al increased by (1.06 +/- 0.95) mm and Sbal-Sbal increased by (0.36 +/- 1.33) mm in the control group. There was significant difference between two groups.

CONCLUSIONSThe surgical technique of ABS is the most important factor for determining the postoperative alar width. Both techniques have better effect on the Sbal-Sbal width control than the G. lat-G. lat and Al-Al width control. Traditional intraoral ABS can more effectively control the alar width. Both techniques cannot completely control the alar base widening after Le Fort I osteotomy.

Chin retrusion and micrognathia are deformities that are commonly encountered in patients desiring rhinoplasty. Augmentation genioplasty in these patients improves the profile and enhances cosmetic result of rhinoplasty. For chin augmentation, either sliding osteotomy or implant insertion can be used. In alloplastic chin augmentation, rejection, infection of the materials, or resorption of the mandible can be a major problem. Horizontal sliding osteotomy of the mandibular symphysis with advancement of the mobilized segment can be the technique of choice to avoid these disadvantages. Here we report 2 cases of acquired nasal deformity and chin retrusion treated with simultaneous rhinoplasty and sliding genioplasty with a brief literature review.
Chin ; Congenital Abnormalities ; Cosmetics ; Genioplasty ; Humans ; Mandible ; Nose ; Nose Deformities, Acquired ; Osteotomy ; Rejection (Psychology) ; Rhinoplasty

On the aesthetic surgical point of view, the hump nose characterized by nasal hump, straight or convex dorsal profile, drooping nasal tip and acute nasolabial angle results in strong and older facial image. To improve these hump nose in Asians, classical Joseph's nasal hump reduction or conservative humpectomy followed by nasal tip-plasty and augmentation rhinoplasty were applied according to hump size. However, these methods of hump nose correction are insufficient for satisfactory results due to unfavorable dorsal profile and hump recurrence. Therefore, the author presents systemic and important surgical considerations obtained by surgical experiences from more than 200 cases to produce consistent and complete correction of hump nose without recurrence. From April of 2004 to May of 2008, total 228 patients underwent hump nose correction recognizing surgical considerations presented in this research. Of these patients, 38 patients were secondary cases of hump nose due to unfavorable dorsal profile and hump recurrence. The author obtained aesthetically satisfactory results without recurrence for mean 17 months follow up periods in all patients without any significant surgical complications. Measurement results are as follows: 1.average decrease in nasal length was 3.4mm, 2. average decrease in nasal width was 2.2mm, 3. average increase in nasal tip projection was 4.3mm, 4. average increase of nasolabial angles was 12.2 degree. In conclusion, hump nose correction by recognizing surgical considerations presented in this research is an effective, reliable and valuable method in correcting hump nose without recurrence and improving lateral nasal profile aesthetically.
Asian Continental Ancestry Group ; Follow-Up Studies ; Humans ; Nose ; Nose Deformities, Acquired ; Recurrence ; Rhinoplasty

Cartilage extension and nasal envelop expansion play a main role incorrecting short or contracted nose. Despite numerous studies for cartilage expansion, there has been no reports of nasal skin elongation methods. We hereby preport a new method for expansion of nasal envelop with a comprehensive understanding of anatomical structures. From April 2009 to September 2010, 6 patients underwent operations to correct short or contracted nose. Two separating procedures were included for nasal envelop elongation; division of muscle(Procerus, Transverse nasali, Levator labii superior alaque nasi: PTL muscles) confluence located at nasal hinge and release of transverse nasalis sling. To estimate the degree of nasal envelop extension, forced skin traction test was performed. Comprehensive research with fresh cadaver was held to study the relationship between nasal SMAS and surrounding structures. Average 3.8mm elongation was documented by forced skin traction testafter the procedure. In the fresh cadaver study, transverse nasalis sling and PTL muscle confluence were firmly attached to the supportive framework. From our clinical experience and cadaver study, we discovered that release of transverse nasalis sling and division of PTL muscle confluence are the main factors for nasal envelop expansion in short or contracted nose.
Cadaver ; Cartilage ; Congenital Abnormalities ; Contracts ; Humans ; Muscles ; Nose ; Nose Deformities, Acquired ; Rhinoplasty ; Skin ; Traction

BACKGROUND AND OBJECTIVES: The purpose of this study was to compare the effectiveness of percutaneous and endonasal lateral osteotomy for the correction of deviated nose. SUBJECTS AND METHOD: Medical records of 60 patients who underwent rhinoplasty to correct deviated nose were reviewed retrospectively. Patients with unilateral osteotomy, revision rhinoplasty, spreader graft, or who had no preoperative or postoperative photos were excluded from the study. The patients were categorized into two groups, which either had C-shaped deviation or I-shaped deviation. Preoperative and postoperative deviation angles were measured and their differences were analyzed according to the approach methods. RESULTS: In the percutaneous approach group, 26 patients had C-shaped deviation and 10 patients had I-shaped deviation, whereas in the endonasal approach group, 17 patients had C-shaped deviation and 7 patients had I-shaped deviation. In the percutaneous approach, the deviation angle was statistically improved in the C-shaped deviation, but in the endonasal approach, it was statistically improved in the C-shaped and I-shaped deviation after surgery. In the C-shaped deviation, the average degrees of improvement of percutaneous and endonasal approach were 5.2°±3.6° and 7.9°±5.3°, respectively, which showed significant difference. However, in the I-shaped deviation, the average degrees of improvement of percutaneous and endonasal approach were 2.9°±1.3° and 2.9°±1.0°, respectively, with no significant difference. CONCLUSION: The improvement of deviation angle following osteotomy may be different according to the approach methods for deviated nose. Endonasal approach was more suitable than percutaneous approach in the correction of I-shaped deviated nose.
Humans ; Medical Records ; Methods ; Nose Deformities, Acquired ; Nose ; Osteotomy ; Retrospective Studies ; Rhinoplasty ; Surgical Procedures, Operative ; Transplants