Triangular Resection of the Upper Lateral Cartilage for Middle Vault Deviation

Abstract

ObjectivesMiddle 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.MethodsA 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.ResultsThe 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 5.66º to 2.37º immediately (P<0.001). Middle vault deviation also improved from 169.50º to 177.24º (P<0.001). Long-term results were 2.49º (P=0.015) for nasal tip deviation and 178.68º (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).ConclusionTriangular 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.

One-Unit Osteotomy to Correct Deviated Bony Dorsum

“…In our opinion, correction of the dorsal septum may affect the external cartilaginous deviation of the rhinion area. However, in the present study as well, even after one-unit osteotomy and endonasal septoplasty, deviation in the rhinion area remained in some cases, in which procedures such as triangular resection of the upper lateral cartilage were additionally performed [ 8 ]. Therefore, corrective rhinoplasty is a summation of multiple individual procedures to fix deviation at various sites, which makes it difficult to identify the effect of one-unit osteotomy exclusively.…”

“…The main purpose of this procedure is to balance the width of both lateral walls and preserve structural integrity. Asymmetry of the bony lateral wall in the deviated bony vault is accompanied by widening and lengthening of one side of the bony vault; in our new technique, triangular resection of the upper lateral cartilage is performed to address the middle vault deviation [ 8 ]. Therefore, this one-unit osteotomy technique might be essential if the size of the bony lateral wall is dissimilar.…”

“…After septoplasty, columellar and marginal incisions are made followed by supraperichondrial and subperiosteal superficial musculoaponeurotic system flap elevation if there is a need for augmentation or middle vault correction [ 8 ]. Thereafter, the one-unit osteotomy was performed as follows ( Fig.…”

“…All participants, including the controls who underwent conventional osteotomy, underwent facial photography preoperatively and 3 months postoperatively. The bony vault deviation angle was measured on facial photographs using a protractor according to previously reported methods [ 8 , 9 ]. The bony vault deviation angle was assessed preoperatively and postoperatively as the angle between the rhinion and midline from the nasion to the philtrum ( Fig.…”