The lateral osteotomy in rhinoplasty: clinical and radiographic rationale for osteotome selection

A preferred osteotome for endonasal osteotomy would facilitate reliable, complete osteotomies with minimal soft-tissue trauma. In this report, a radiographic evaluation of the bony lateral nasal wall thickness along the track of a high-low-high osteotomy was undertaken to guide the determination of appropriate osteotome size. Bone window axial computed tomographic scans were evaluated in 56 patients with a mean age of 48 years (range, 19 to 86 years). The average thickness along the site of lateral osteotomy was determined to be 2.47 mm (standard deviation, 0.47) in male patients and 2.29 mm (standard deviation, 0.40) in female patients. On the basis of these data, clinical evaluation of prototype 3- and 2.5-mm low-profile guarded osteotomes was undertaken in comparison with a "standard" 4-mm low-profile guarded osteotome to assess both their reliability and the degree of intranasal trauma, as reflected by intranasal mucosal tears. Although 2- and 3-mm unguarded osteotomes are time-tested, they may be reliable only in the hands of the most experienced surgeons. Therefore, a low-profile guard was included in the osteotome design to allow the surgeon to engage the bone securely and minimize the risk of slippage. Forty patients underwent rhinoplasty, for a total of 80 lateral osteotomies; the mean age of the patients was 38 (range, 16 to 75). In all cases, lateral osteotomies were accomplished with one pass. The 4-mm osteotome causes intranasal mucosal tears in 95 percent of osteotomies, the 3-mm osteotome in 34 percent, and the 2.5-mm in 4 percent. Early postoperative edema and ecchymosis were comparable among the groups. One patient, who underwent osteotomies with a 4-mm osteotome, had excessive postoperative narrowing, possibly due to his wearing of eyeglasses earlier than directed. This report suggests that proper selection of osteotome and attention to proper surgical technique results in a reliable, minimally traumatic lateral osteotomy through the endonasal approach. The 2.5-mm osteotome was reliable and the least traumatic to soft tissue of the osteotomes evaluated.     

Asymmetric incision for open rhinoplasty in cleft lip nasal deformity.

One of the problems in the correction of the unilateral cleft lip nasal deformity is the alar web deformity on the mediosuperior side of the nostril. A number of methods for the correction of the alar web deformity have been introduced, but no single procedure has been identified as the standard. In this report, the incision line of the open rhinoplasty was modified and the alar web deformity was corrected by using an incision and closure. Open rhinoplasty with the asymmetric incision was performed on 18 patients with unilateral cleft lip nasal deformity. The incision line used in the normal side was the usual intranasal rim incision line and that used for the columella was the transcolumella incision line. For the cleft side, an intranasal rim incision line was plotted after the rim was lifted upward with forceps to achieve symmetry of the nasal tip. After removal of the forceps, the incision line of the cleft side was displaced outside the nostril. After such an incision, the alar cartilage mobilization and suspension were performed with or without the conchal cartilage graft. All patients used nasal retainers for 6 months after the procedures. So far, satisfactory results have been obtained with the modification of the incision line for open rhinoplasty. This method is unique in designing the incision line, and its procedure is rather simple. The postoperative follow-up period has been 12 to 26 months. A long-term follow-up is still needed, especially in growing children.     

The role of open rhinoplasty in the management of nasal dermoid cysts

The nasal dermal sinus cyst is one of many midline nasal masses that often pose diagnostic and treatment dilemmas for the plastic and reconstructive surgeon. The differential diagnosis of the midline nasal mass includes both congenital and acquired processes. A thorough understanding of its cause is crucial to treatment. A comprehensive discussion of the pathogenesis, diagnosis, sequelae, and surgical management, and a representative case analysis, of the nasal dermal sinus cyst is presented to delineate the role of open rhinoplasty in optimizing the care of this congenital nasal deformity.     

Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty

Most techniques for secondary rhinoplasty assume that useful residual remnants of the tip cartilages remain, but frequently the alar cartilages are missing--unilaterally, bilaterally, completely, or incompletely--with loss of the lateral crura, middle crura, and parts of the medial crura. In such severe cases, excision of scar tissue and the residual alar remnants and their replacement with nonanatomic tip grafts have been recommended. Multiple solid, bruised, or crushed cartilage fragments are positioned in a closed pocket or solid shield-shaped grafts are fixed with sutures during an open rhinoplasty. These onlay filler grafts only increase tip projection and definition. Associated tip abnormalities (alar rim notching, columellar retraction, nostril distortion) are not addressed. Problems with graft visibility, an unnatural appearance, or malposition have been noted. Fortunately, techniques useful in reconstructive rhinoplasty can be applied to severe cosmetic secondary deformities. Anatomic cartilage replacements similar in shape, bulk, and position to normal alar cartilages can be fashioned from septal, ear, and rib cartilage, fixed to the residual medial crura and/or a columellar strut, and bent backward to restore the normal skeletal framework of the tip. During an open rhinoplasty, a fabricated and rigid framework is designed to replace the missing medial, middle, or lateral crus of one or both alar cartilages. The entire alar tripod is recreated. These anatomic alar cartilage reconstructive grafts create tip definition and projection, fill the lobule and restore the expected lateral convexity, position the columella and establish columellar length, secure and position the alar rim, and brace the external valve against collapse, support the vestibular lining, and restore a nostril shape. The anatomic form and function of the nasal tip is restored. This technique is recommended when alar cartilages are significantly destroyed or absent in secondary or reconstructive rhinoplasty and the alar remnants are insufficient for repair. Anatomically designed alar cartilage replacements allow an aesthetically structured skeleton to contour the overlying skin envelope. Problems with displacement are minimized by graft fixation. Graft visibility is used to the surgeon's advantage. A rigidly supported framework with a nasal shape can mold a covering forehead flap or the scarred tip skin of a secondary rhinoplasty and create a result that may approach normal. Anatomic alar cartilage reconstructions were used in eight reconstructive and eight secondary rhinoplasties in the last 5 years. Their use in the repair of postrhinoplasty deformities is emphasized.     

Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty

Submucosal placement of strips of cartilage along the anterior border of the septum--the spreader graft--has proved to be an effective method for reconstructing the roof of the middle vault. It is recommended in all primary rhinoplasty patients in whom resection of the roof of the upper cartilaginous vault is a necessary part of the surgical plan.     

Achieving consistency in life cycle assessment practice within the European construction sector: the role of the EeBGuide InfoHub

Purpose

The objective of the paper is to discuss the role of a new guidance document for life cycle assessment (LCA) in the construction sector available as an online InfoHub.

Methods

This InfoHub derives from the EeBGuide European project that aimed at developing a guidance document for energy-efficient building LCA studies. The InfoHub is built on reference documents such as the ISO 14040-44 standards, the EN 15804 and EN 15978 standards as well as the ILCD Handbook. The guidance document was filled with expertise and knowledge of several experts. The focus was put on providing scientifically sound, yet practical guidance.

Results

The EeBGuide InfoHub is an online guidance document, setting rules for conducting LCA studies and giving instructions on how to do this. The document has a section on buildings—new and existing—and a section on construction products. It is structured according to the life cycle stages of the European standards EN 15804 and EN 15978, covering all aspects of LCA studies by applying provisions from these standards and the ILCD handbook, wherever applicable. The guidance is presented for different scopes of studies by means of three study types. For the same system boundaries, default values are proposed in early or quick assessment (screening and simplified LCA) while detailed calculation rules correspond to a complete LCA. Such approach is intended to better match the user needs in the building sector.

Conclusions and recommendations

This paper can be viewed as a contribution to the ongoing efforts to improve the consistency and harmonisation in LCA studies for building products and buildings. Further contributions are now needed to improve building LCA guidance and to strengthen links between research, standardisation and implementation of LCA in the construction practice.     

A new nasal acoustic reflection technique to estimate pharyngeal cross-sectional area during sleep.

The conventional acoustic reflection technique in which acoustic waves are launched through the mouth cannot be applied during sleep, nor can it be applied to the nasopharynx, which is the major site of occlusion in patients with obstructive sleep apnea syndrome. We propose a new technique of nasal acoustic reflection to measure pharyngeal cross-sectional areas including the nasopharynx. The acoustic waves are introduced simultaneously to both nostrils during spontaneous nasal breathing. A new algorithm takes into account the nasal septum with asymmetric nasal cavities on both sides and assumes prior knowledge of the cross-sectional area of the nasal cavities and the position of the nasal septum. This method was tested on an airway model with a septum and on healthy human subjects. The conventional technique gave inaccurate measurements for pharyngeal cross-sectional areas for an airway model with asymmetric branching, whereas the new technique measured them almost perfectly. The oro- and hypopharyngeal cross-sectional area measurements acquired by the new method were not different from those obtained by the conventional method in normal subjects. This new method can be used as a monitor of upper airway dimensions in nocturnal polysomnography.     

Dynamic rhinoplasty for the plunging nasal tip: functional unity of the inferior third of the nose

To achieve permanent results for the correction of a drooping nasal tip, it is important to understand the mechanism responsible for the caudal rotation of the tip when a person speaks or smiles. This mechanism can be considered to depend on a "functional unity" formed by three components: (1) the cartilaginous framework (alar cartilages and accessories acting as a single structure); (2) muscular motors (m. levator labii superioris alaeque nasi and depressor septi nasi); and (3) gliding areas (apertura piriformis, the valvular mechanism between the upper lateral cartilages and alar cartilages, the lax tissue of the nasal dorsum, and the membranous septum). We describe a new anatomical and functional concept responsible for the plunging of the nasal tip. When a person smiles, the functional unit is activated by a combination of two forces acting simultaneously in opposite directions that rotate the tip caudally and elevate the nasal base. The levator moves the alar base upward and the depressor pulls the tip caudally. To correct the drooping tip, the transcartilaginous incision is extended laterally, and the lateral portion of the alar arch is dissected free from the skin and the mucosa, thus exposing the accessory cartilages. The arch is then severed at the level of the accessories to allow the cephalad rotation of the domes. The muscle insertions are dissected free from the accessories and a section of the muscle and, if necessary, the accessory cartilages, is removed. From January of 1991 onward, 312 patients have had this ancillary procedure performed in addition to the basic rhinoplasty technique.