New Suturing Techniques to Reconstruct the Keystone Area in Extracorporeal Septoplasty

Rhinoplasty is universally considered as the most demanding procedure in facial plastic surgery. Secondary rhinoplasty is its crown jewel, even more complex, and likewise highly fascinating. The evolution of thought and practice in rhinoplasty in the last decades has been quick and steady, progressively acknowledging the importance of maintaining structure in primary rhinoplasty and rebuilding structure in secondary procedures. No longer is the paradigm to achieve a small, thin, and pointy nose, but rather a well-proportioned nose which looks natural, albeit elegant and breathing well. Rib is an essential tool in many secondary procedures, and thus some important concepts have to be well understood and some finesse points mastered. This will provide an elegant reconstruction, identical if possible, or at least not far apart, to what could be achieved by a well-executed primary rhinoplasty, while avoiding the feared luck of a bulky nose stuffed with grafts. These guiding concepts and specific nuances regarding harvesting rib and working with it are the scope and contents of this article.

Section: Septum and L Strut And Aesthetic Dorsal Linesmentioning

confidence: 99%

Current Practical Concepts for Using Rib in Secondary Rhinoplasty

Robotti¹,

Penna

2019

“…Another more complicated but highly effective option for internal fixation of the bony pyramid is the transcutaneous transosseous cerclage suture (TTCS) as described by Rezaeian and coworkers. 33 Like the crisscross suture, the TTCS was developed to reattach the neoseptal construct following extracorporeal septoplasty and greatly enhances stabilization of the aggressively mobilized bony pyramid.…”

Section: Treatment Of the Wide Bony Vaultmentioning

confidence: 99%

Treating the Deviated or Wide Nasal Dorsum

Davis

Foulad

2017

Both deviation and excessive width of the nasal dorsum result in conspicuous facial disharmony and are often attended by nasal airway dysfunction. Whether the result of developmental growth disturbances, nasal trauma, failed nasal surgery, or combinations therein, deviation and splaying of the nasal dorsum can be exceedingly difficult to treat. Individualized treatment is paramount because contour variations are seemingly endless, and a careful preoperative assessment of the anatomic, physiologic, cosmetic, and psychosocial factors that characterize the deformity is necessary to devise an effective patient-specific treatment plan. Ensuring the linearity, strength, alignment, and aesthetically pleasing profile dimensions of the nasal L-strut is the requisite first step in successful treatment. Releasing all deformed components in a controlled and precise manner using powered instrumentation (whenever possible) to facilitate minimally traumatic and effective repositioning, followed by structural reconstitution of the skeletal framework using autologous graft materials, and then consolidation of the newly created construct with suture fixation completes the transformation to normalcy. Paying equal attention to both cosmetic and functional wellness, while simultaneously seeking to maximize structural stability, serves to optimize the final outcome.

“…9 A major drawback of this technique is destabilization of the junction of the quadrangular cartilage and bones (keystone area), with resultant requirement for unique forms of fixation, such as percutaneous sutures, or sutures to the ethmoid or nasal bones. 13 However, even in the most experienced of surgeons, notching or saddling may occur as a result of keystone instability. 9 ASR has been developed to replace the extracorporeal septoplasty technique to minimize destabilization of the keystone (and thus preserve dorsal contour).…”

Section: Anterior Septal Reconstructionmentioning

confidence: 99%

Correcting Deviations of the Lower Third of the Nose

Moubayed

Most

2017

By convention, a "deviated nose" is one in which the lower third is asymmetric with regard to the midline. The lower third of the nose is composed of the lower cartilages, as well as the dorsal and caudal nasal septum. Not only does the deviated nose cause a cosmetic deformity that is often disconcerting for patients, but it may also be associated with functional problems. Airway obstruction may result from a narrowed internal nasal valve in the middle third or from a deviated caudal septum in the lower third. The most common deviation involves both the middle and lower thirds and often requires addressing the underlying dorsal and caudal septum. The most effective technique to correct this type of deviation is the principle of extracorporeal septoplasty, either the traditional or modified, such as the anterior septal reconstruction (ASR) technique combined with the clocking suture. An isolated middle third deviation may be treated with a camouflage graft or a unilateral spreader graft. An isolated lower third deviation involving the septum should be treated with ASR. When an isolated lower third deviation only involves the lower cartilages, it may be corrected using suture techniques, cartilage division techniques, or grafting.