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.

Rhinoplasty ; Nose Deformities, Acquired ; Esthetics

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

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

OBJECTIVES: Middle vault deviation has a significant effect on the aesthetic and functional aspects of the nose, and its management continues to be a challenge. Spreader graft and its modification techniques have been focused, but there has been scarce consideration for removing surplus portion and balancing the upper lateral cartilage (ULC). This study aimed to report the newly invented triangular-shaped resection technique (“triangular resection”) of the ULC and to evaluate its efficacy for correcting middle vault deviation. METHODS: A retrospective study included 17 consecutive patients who presented with middle vault deviation and underwent septorhinoplasty by using triangular resection at a tertiary academic hospital from February 2014 and March 2016. Their outcomes were evaluated pre- and postoperatively including medical photographs, acoustic rhinometry and subjective nasal obstruction using a 7-point Likert scale. RESULTS: The immediate outcomes were evaluated around 1 month after surgery, and long-term outcomes were available in 12 patients; the mean follow-up period was 9.1 months. Nasal tip deviation angle was reduced from 5.66° to 2.37° immediately (P < 0.001). Middle vault deviation also improved from 169.50° to 177.24° (P < 0.001). Long-term results were 2.49° (P=0.015) for nasal tip deviation and 178.68° (P=0.002) for middle vault deviation. The aesthetic outcome involved a complete correction in eight patients (47.1%), a minimally visible deviation in seven patients (41.2%) and a remaining residual deviation in two patients (11.8%). Pre- and postoperative minimal cross-sectional areas (summation of the right and left sides) were 0.86 and 1.07, respectively (P=0.021). Fifteen patients answered about their nasal obstruction symptoms and the median symptom score had alleviated from 6.0 to 3.0 (P=0.004). CONCLUSION: Triangular resection of the ULC is a simple and effective method for correcting middle vault deviation and balancing the ULCs without complications as internal nasal valve narrowing.
Cartilage* ; Follow-Up Studies ; Humans ; Methods ; Nasal Cartilages ; Nasal Obstruction ; Nose ; Nose Deformities, Acquired ; Retrospective Studies ; Rhinometry, Acoustic ; Rhinoplasty ; Transplants

OBJECTIVES: To explore the micro-plastic operative treatment of deviated nose combined with nasal septum deviation. METHODS: We designed the incision at the caudal side of the nasal septum. The three-line reduction method for correcting nasal septum deviation was performed. The connection of the caudal nasal septum and the anterior nasal spine was reposited. The micro-plastic surgery with fixed suture was used to correct the deviated nose. RESULTS: After the surgery, the nasal septum deviation was corrected, whose nasal function and symptoms improved without nasal adhesion, nasal septum perforation or other complications. Meanwhile, the nasal tips were in the middle place and nasal dorsums were straight. The aesthetic outcome was satisfactory. CONCLUSIONS Compared to the traditional orthopedic technique, the micro-shaping technique can be used for the homochromous operation of crooked nose combined with nasal septum deviation with less injury and lower risk. We suggest this micro-shaping technique be used in a rational way.
Humans ; Nasal Septum ; surgery ; Nose ; surgery ; Nose Deformities, Acquired ; surgery ; Reconstructive Surgical Procedures ; Rhinoplasty ; methods ; Sutures

OBJECTIVETo investigate the therapeutic effect of alar rotation flap for severe alar retraction.

METHODSPatients with severely retracted alar underwent ala reconstruction using alar rotation flaps and autogenous cartilage batten grafts. First, costal cartilage was used to reshape the nasal tip and nasal dorsum. Then cartilage patch was used to extend and thicken the retracted alar. Then the alar rotation flap was transferred to correct retracted alar.

RESULTSFourteen patients with severe alar retraction underwent alar reconstruction with alar rotation flap and alar batten grafts. The alar retraction was corrected in all cases, with improvements functionally and aesthetically. No recurrence of alar retraction was noted. The incision healed with acceptable cosmetic results, with obvious scar in only one patient (one side).

CONCLUSIONSThe alar rotation flap is an effective and reliable surgical option to correct severe alar retraction. Scar can be kept inconspicuous by precise placement of the incision within the junction of the ala and the nasal dorsum, following principles of the aesthetic nasal subunits.

Cartilage ; transplantation ; Cicatrix ; prevention & control ; Costal Cartilage ; transplantation ; Esthetics ; Humans ; Nose Deformities, Acquired ; surgery ; Rhinoplasty ; methods ; Rotation ; Surgical Flaps

In full-thickness defects of the nasal alar rim, to achieve projection and maintain airway patency, cartilage graft is frequently needed. However, cartilage graft presents a challenge in considerations such as appropriate donor site, skeletal shape and size, and healing of the donor area. To avoid these demerits, we tried primary closure of alar rim defects by also making the contralateral normal ala smaller. We treated two patients who had a full-thickness nasal alar defect after tumor excision. Cartilage graft was considered for the reconstruction. However, their alar rims were overly curved and their nostril openings were large. To utilize their nasal shape, we did primary closure of the defect rather than cartilage graft, and then downsized the contralateral nasal ala by means of wedge resection to make the alae symmetric. Both patients were satisfied with their aesthetic results, which showed a smaller nostril and nearly straight alar rims. Moreover, functionally, there was no discomfort during breathing in both patients. We propose our idea as one of the reconstruction options for nasal alar defects. It is a simple and easy-to-perform procedure, in addition to enhancing the nasal contour. This method would be useful for patients with a large nostril and an overly curved alar rim.
Cartilage ; Humans ; Nose Deformities, Acquired ; Reconstructive Surgical Procedures ; Respiration ; Tissue Donors ; Transplants

OBJECTIVETo observe the origins and insertions of Pitanguy ligament,in order to find the anatomically theoretical basis for the treatment of nasal deformity such as drooping nose, short columella, gingival show.

METHODS15 cadaveric heads fixed by 10% formalin were used. 12 specimens underwent nasal anatomic study. The skin was incised, along the nasal midline to expose the Pitanguy ligament. The origin of Pitanguy ligament and its relationship with surrounding tissue were studied. Then the Pitanguy ligament was taken out for HE staining. Longitudinal section along the ligament was observed. 3 specimens underwent harvesting of full-thickness nasal tissue from skin to periosteal membrane. Then the samples were used for HE staining to show histologic study of ligament at horizontal section.

RESULTSPitanguy ligament originates in the midline of lower third of the nasal superficial musculoaponeurotic system, extends down to the tip along the midline of the nasal dorsum and then turns backwards at the nasal tip, and runs between the medial crura of the lower lateral cartilages, inserts into the base of columella. Its muscle is connected with the orbicularis oris muscle and the depressor septi nasi muscle. HE staining showed the ligament consists of fibrous connective tissue, muscle tissue and other ingredients, but without cartilage.

CONCLUSIONSPitanguy ligament exists with complex histological composition, so its name is still controversial. Because it has multiple connection with the orbicularis oris muscle and the depressor septi nasi muscle, so cutting or shortened the Pitanguy ligament can treat deformity of nose and lip by adjustment of nasolabial angles and the nasal length.

Cadaver ; Cartilage ; anatomy & histology ; Facial Muscles ; anatomy & histology ; Humans ; Ligaments ; anatomy & histology ; Lip ; anatomy & histology ; Nasal Septum ; anatomy & histology ; Nose ; anatomy & histology ; Nose Deformities, Acquired ; pathology ; surgery ; Subcutaneous Tissue ; anatomy & histology

Recently, in Korea, the septal extension graft from the septum or rib has become a common method of correcting a small or short nose. The success rate of this method has led to the blind faith that it provides superior tip projection and definition, and to the failure to notice its weaknesses. Even if there is a sufficient amount of cartilage, improper separation or fixation might waste the cartilage, resulting in an inefficient operation. Appropriate resection and effective fixation are essential factors for economical rhinoplasty. The septal extension graft is a remarkable procedure since it can control the nasal tip bidirectionally and three dimensionally. Nevertheless, it has a serious drawback since resection is responsible for septal weakness. Safe resection and firm reconstruction of the framework should be carried out. Operating on the basis of the principle of "safe harvest" and rebuilding the structures is important. Further, it is important to learn several techniques to manage septal weakness, insufficient cartilage quantity, and failure of the rigid frame during the surgery.
Asian Continental Ancestry Group* ; Cartilage ; Ear Cartilage ; Humans ; Korea ; Nasal Septum ; Nose ; Nose Deformities, Acquired ; Rhinoplasty* ; Ribs ; Transplants

OBJECTIVE: To investigate the clinical effect of negative pressure drainage after septum surgery. METHOD: One hundred and two cases with septum deviation were randomly divided into two groups, i. e. experimental group and controlling one. With 51 cases in each. Degree of comfort and complication of two groups were compared. RESULT: The cases in experimental group showed significantly relieved postoperative reaction with negative pressure drainage, when compared with that of controls, the incidence of complication were not increased. CONCLUSION Negative pressure drainage can be taken as one of the ideal materials for hemostasia after septum surgery.
Drainage ; Endoscopy ; Humans ; Incidence ; Nasal Septum ; surgery ; Nose Deformities, Acquired ; Postoperative Period