The Cyrano nose: a clinical review of hemangiomas of the nasal tip.

It is always difficult to establish one preferred management program for all patients with any lesion, but serious consideration must be given to "no-touch" management of cavernous or capillary-cavernous hemangiomas of the nasal tip. This requires frequent consultations with the parents to furnish psychological support. If extreme pressure from the parents makes surgery inevitable, the operation should be limited to the immediate confines of the nasal tip.     

AlloDerm for dorsal nasal irregularities

After nasal surgery, thinning of the nasal skin, bony irregularities, or adhesions of dorsal skin to underlying bone can all occur. These problems can be solved by using either alloplastic materials or various autogenous tissues. In this study, AlloDerm, a dermal replacement derived from cadaveric skin, has been used to cover the osseocartilaginous framework of the nose in an attempt to achieve a smooth contour and a natural feel in secondary rhinoplasties. Fifteen patients were treated and observed for a minimum of 24 months. Clinically palpable or visible bony irregularities were successfully covered, and adhesions of dorsal skin to nasal bones were diminished. Prolonged but not socially unacceptable dorsal nasal swelling, which resolved during the first 4 months, seemed to be the only problem related to its use. With this limited experience, AlloDerm was found to be useful in secondary nasal surgery to cover osseocartilaginous irregularities, to eliminate the adhesions between nasal bones and overlying skin, and to create a smooth nasal dorsum.     

Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle

Herein is described a technique that uses a combination of local flaps to reconstruct large defects involving the nasal dorsum and cheek. The flaps used are a transposition flap elevated from the area adjoining the defect and bilateral cheek advancement flaps. This technique leaves all suture wounds at borders of the aesthetic subunits that have been described previously. Color and texture matches were good and symmetrical. The transposition flap can be modified according to whether the defect includes the nasal tip. After raising the cheek advancement flap, it is also possible to use a dog-ear on the nasolabial region for any alar defects. Nine patients were treated using this procedure. The technique is very reliable (no complications such as congestion and skin necrosis in our series) and is easy to perform. One patient had palpebral ectropion after the operation and underwent secondary repair. In this series, defects measuring 45 x 30 mm in maximum diameter and including the nasal dorsum, nasal tip, ala, and cheek were treated.     

Rhinoplasty: the retractable roof

A new operative technique is described in which the natural curved nasal dorsum is retained in a modified fashion. Specifically, the nasal dorsum is elevated, the nasal height is reduced, and then the newly designed roof is lowered. Based on a minimum 1-year follow-up of 14 patients and a total experience of 28 patients, the procedure has the following advantages: (1) near normal anatomic structure is retained, (2) common secondary dorsal deformities are avoided, (3) the retained roof can function as a spreader graft, (4) the skin attachment with its attendant blood supply is preserved, and (5) the graft can be removed primarily or easily modified secondarily. Disadvantages appear to be the need for greater finesse and a limited follow-up of 2 years.     

The nasal dorsum as a donor site for the correction of alar, lobular, and columellar malformations

There is a wide variety of donor sites available for minor nasal reconstructions involving alar, lobular, and columellar defects. Unfortunately, the problems all these sites have in common are that the color match may be unsatisfactory or that the end result may be marred by conspicuous scarring. If nasal-skin resources could be fully exploited, the elimination of these two important problems could become an obtainable goal.This article discusses the potential of the nasal dorsum as a donor site and describes methods that were used to try to achieve this goal. Skin redistribution, skin expansion, and skin distraction methods were used in 28 patients with alar (n = 13), lobular (n = 8), and columellar (n = 7) malformations and who had been followed up since the early 1980s.     

Nasal reconstruction based on aesthetic subunits in Orientals

Reconstruction based on the aesthetic subunit principle has yielded good aesthetic outcomes in patients with moderate to severe nasal defects caused by trauma or tumor resection. However, the topographic subunits previously proposed are often unsuitable for Orientals. Compared with the nose in white patients, the nose in Orientals is low, lacks nasal muscle, and has a flat glabella; the structural features of the underlying cartilage and bone are not distinctly reflected in outward appearance. The authors devised aesthetic subunits suitable for Orientals, and they used these units to reconstruct various parts of the nose. The major difference between these units and those presented previously is the lack of soft triangles and the addition of the glabella as an independent unit. The authors divided the nose into the following five topographic units: the glabella, the nasal dorsum, the nasal tip, and the two alae. The border of the nasal dorsum unit was extended to above the maxillonasal suture. The basic reconstruction techniques use a V-Y advancement flap from the forehead to reconstruct the glabella, an island flap from the forehead to reconstruct the nasal dorsum and nasal tip, a nasolabial flap to reconstruct an ala, and a malar flap to reconstruct the cheek. A combination of flaps was used when the defect involved more than one unit. This concept was used for nasal reconstruction in 24 patients. In one patient undergoing reconstruction of the nasal dorsum and in one undergoing reconstruction of the nasal tip, the texture of the forearm flap did not match well, which resulted in a slightly unsatisfactory aesthetic outcome. In one patient in whom the glabella, nasal dorsum, and part of the cheek were reconstructed simultaneously, a web was formed at the medial ocular angle, and a secondary operation was subsequently performed using Z-plasty. In one patient undergoing reconstruction with a forehead flap, defatting was required to reduce the bulk of the subcutaneous flap pedicle at the glabella. However, suture lines were placed in the most inconspicuous sites in all patients, and the use of a trapdoor contraction emphasized the three-dimensional appearance of the nose. The use of these aesthetic subunits for reconstruction offers several advantages, particularly in Oriental patients. Because the nasal dorsum is reconstructed together with the side walls, tenting of the nasal dorsum is avoided, which prevents a flat appearance of the nose. A forehead flap is useful in the repair of complex defects. Defects of the alae should be separately reconstructed with a nasolabial flap to enhance the effect of the trapdoor contraction and to highlight the three-dimensional appearance of the nose. Candidates for reconstruction should be selected on the basis of nasal structure. The results suggest that these units can also be used in some white patients.     

Nasal reconstruction with a forehead flap in children younger than 10 years of age

Nasal reconstruction has been analyzed extensively in adults but not in children. The purpose of this article is to review the authors' experience with the forehead flap for nasal reconstruction in 10 children under the age of 10 during a 10-year period. Outcomes were assessed by an objective grading system for cosmetic surgical results. Subjective criteria were also applied by an assistant surgeon and by the patients' relatives. Appropriate results were obtained by the following principles: (1) A modified approach that considers three subunits consisting of the dorsum, tip, and ala was used; (2) a forehead flap is the best option for an entire subunit or a full-thickness defect repair; (3) the forehead flap design should be paramedian, oblique, and opposite to the major defect to avoid the hairline and allow better caudal advancement; (4) ear or costal cartilages are good options for structural support (the septum is a nasal growth center that should not be touched); (5) infundibular undermining of vestibular mucosa, turnover flaps, and skin grafts are good options for internal lining; (6) reconstruction is a three-stage procedure (an intermediate operation is added to thin the flap and perform secondary revisions for lining and support); (7) reconstruction should be completed before the child is school aged, to achieve good aesthetic results immediately and avoid psychosocial repercussions; and (8) the reconstructed nose, with skin, lining, and support, will grow with the child (no final surgery should be planned at the age of 18, other than revisions of late complications).     

Grafting the nasal dorsum with tandem ear cartilage

A technique for autogenous grafting of the nasal dorsum with ear cartilage is suggested based on the results of 25 consecutive cases. The technique involves (1) harvesting the entire cymba conchae and cavum conchae of the ear; (2) separating them and suturing them to each other in tandem fashion; (3) filling the underside concavity of the cymba conchae part of the graft with scraps of cartilage; (4) avoiding any bruising or crushing of the graft; and (5) filling any minor residual irregularities of the dorsum with soft tissue or cartilage from the cephalic trim of the lateral crus. The results suggest a consistent augmentation of the nasal dorsum for deficiencies from 3 to 6 mm in size. Four of the 25 cases did require secondary correction for dorsal convexity, inadequate augmentation, and surface irregularities. The technique, however, has been helpful in that ear cartilage is invariably available, allowing septum to be used for more important grafts. The procedure is easily performed under local anesthesia with no significant distortion to the donor site.     

Supratip deformity: a closer look

Supratip deformity, a hallmark of a poorly executed rhinoplasty or an inauspicious healing, continues to plague the novice often and the experts on occasion. A clinical and histopathologic study was conducted to search for the surgical causes of this deformity and its histologic presentation. An organized, logical management program was then developed. Clinically, supratip fullness was observed in both primary (26 of 298 patients; 9 percent) and secondary (40 of 112 patients; 36 percent) rhinoplasty candidates. In primary patients, the deformity was the result of inadequate tip projection (pseudodeformity), an overprojected caudal dorsum, a combination of both, or cephalically oriented lower lateral cartilages. In secondary patients, the deformity was caused by an underresected or overresected caudal dorsum, overresected midvault, underprojected tip (pseudodeformity), or a combination of some of these factors. The histopathologic evaluation demonstrated significant fibrosis in the supratip soft tissue of 14 of 16 patients undergoing secondary rhinoplasty without the injection of triamcinolone acetonide and in only 13 of 23 patients who underwent primary rhinoplasty (p<0.05). A supratip deformity can be eschewed by proper resection of the caudal dorsum, avoidance of dead space, restoration of adequate projection to the nasal tip, and an approximation of the supratip subcutaneous tissue to the underlying cartilage using a supratip suture, hence eliminating the dead space. If the problem is noted shortly after surgery, in the presence of collapsible consistency of the supratip tissue and adequate projection, the treatment is taping the supratip tissue as often as it is practical. If no favorable response is elicited in 6 to 8 weeks, thejudicious injection of a small amount of triamcinolone acetonide (0.2 to 0.4 cc of 20 mg/cc) in the deep subcutaneous tissue (not in the dermis) is done. The injection is repeated in 4-week intervals until the desired effect is achieved. If supratip fullness is the consequence of inadequate cartilage resection or inadequate tip projection, surgical correction is needed. The recalcitrant soft-tissue excess in the supratip area is resected, and the subcutaneous soft tissue is approximated to the underlying cartilage. If the dorsum was previously overresected, a cartilage graft to the caudal dorsum or midvault will create an optimal dorsal frame and reduce the potential for a recurrent supratip deformity.     

The Turkish delight: a pliable graft for rhinoplasty

In nose surgery, carved or crushed cartilage used as a graft has some disadvantages, chiefly that it may be perceptible through the nasal skin after tissue resolution is complete. To overcome these problems and to obtain a smoother surface, the authors initiated the use of Surgicel-wrapped diced cartilage. This innovative technique has been used by the authors on 2365 patients over the past 10 years: in 165 patients with traumatic nasal deformity, in 350 patients with postrhinoplasty deformity, and in 1850 patients during primary rhinoplasty. The highlights of the surgical procedure include harvested cartilage (septal, alar, conchal, and sometimes costal) cut in pieces of 0.5 to 1 mm using a no. 11 blade. The fine-textured cartilage mass is then wrapped in one layer of Surgicel and moistened with an antibiotic (rifamycin). The graft is then molded into a cylindrical form and inserted under the dorsal nasal skin. In the lateral wall and tip of the nose, some overcorrection is performed depending on the type of deformity. When the mucosal stitching is complete, this graft can be externally molded, like plasticine, under the dorsal skin. In cases of mild-to-moderate nasal depression, septal and conchal cartilages are used in the same manner to augment the nasal dorsum with consistently effective and durable results. In cases with more severe defects of the nose, costal cartilage is necessary to correct both the length of the nose and the projection of the columella. In patients with recurrent deviation of the nasal bridge, this technique provided a simple solution to the problem. After overexcision of the dorsal part of deviated septal cartilage and insertion of Surgicel-wrapped diced cartilage, a straight nose was obtained in all patients with no recurrence (follow-up of 1 to 10 years). The technique also proved to be highly effective in primary rhinoplasties to camouflage bone irregularities after hump removal in patients with thin nasal skin and/or in cases when excessive hump removal was performed. As a complication, in six patients early postoperative swelling was more than usual. In 16 patients, overcorrection was persistent owing to fibrosis, and in 11 patients resorption was excessive beyond the expected amount. A histologic evaluation was possible in 16 patients, 3, 6, and 12 months postoperatively, by removing thin slices of excess cartilage from the dorsum of the nose during touch-up surgery. This graft showed a mosaic-type alignment of graft cartilage with fibrous tissue connection among the fragments. In conclusion, this type of graft is very easy to apply, because a plasticine-like material is obtained that can be molded with the fingers, giving a smooth surface with desirable form and long-lasting results in all cases. The favorable results obtained by this technique have led the authors to use Surgicel-wrapped diced cartilage routinely in all types of rhinoplasty.     

Refinements in extracorporal septoplasty

Septal deviations interfere with nasal airflow and contribute to deformities in the external appearance of the nose. An aesthetically and functionally satisfactory correction of severe septal deformities or "crippled" septal plates often requires a temporary intraoperative removal of the septal cartilage for appropriate remodeling. This article describes refinements to the previously described technique of extracorporal septoplasty; these refinements have proven useful and have made the procedure safer in the hands of less experienced surgeons. The refinements simplify the straightening methods for the explanted septal plate, achieving a stable and median fixation of the replanted septum while maintaining a satisfactory contour of the nasal dorsum. A milling cutter is used to straighten the irregularities of the explanted septal plate and to thin broadly based anterior nasal spines. When necessary, microplates are added to stabilize the osteotomized and medialized anterior nasal spine. The final positioning of the replanted septal plate is greatly enhanced by a rein stitch, transosseous sutures, and multiple quilt stitches. Additionally, direct fixation of the replanted septum to the edges of the upper lateral cartilages further improves the stability of the reconstruction. Finally, particular care should be taken to avoid residual irregularities of the nasal dorsum; it they occur, these irregularities can be covered with a thin cartilaginous splint or a layer of dehydrated fascia lata or autologous temporal fascia. A total of 436 patients who underwent rhinoseptoplasties at the authors' department during a 1-year period were reviewed. Of these patients, 108 presented with severe septal deviations and underwent an extracorporal septoplasty using the refined techniques described herein. Despite the complexity of the procedure, the patients' satisfaction rates were high, independent of the operating surgeon.     

Long-term outcome of autogenous rib graft nasal reconstruction.

Whereas reconstruction of the hypoplastic nose with rib grafting is common, the long-term outcomes of nasal growth and aesthetics are unknown. This study assessed nasal morphometrics, patient satisfaction, and the perception of nasal appearance by others up to 15 years after nasal reconstruction using cantilevered autogenous chondro-osseous rib grafting with rigid internal fixation in children. Records of all patients who received nasal rib grafts between 1983 and 1998 by one senior surgeon were reviewed. Patients in this study were operated on before their late teens and had greater than 1-year follow-up including serial photographic documentation. Nasal growth was determined by comparing anthropometric measurements preoperatively, perioperatively, and postoperatively. Patient satisfaction was determined through a questionnaire that addressed memory, donor-site morbidity, and nasal perception. Independent, blinded skilled observers who reviewed frontal and lateral photographs of the preoperative, perioperative, and postoperative intervals assessed nasal aesthetics. Thirty-two patients who underwent 38 rib graft reconstructions of the nasal dorsum and tip at an average age of 8.8 years constitute the study population. Six patients underwent secondary augmentation. The average interval between initial nasal reconstruction and evaluation for this study was 7.9 years. Comparative anthropometric measurements before and after surgery documented increases in both tip projection (2.3 percent) and nasal length (3.0 percent) and a decrease in nasolabial angle (1.9 percent). Patient satisfaction interview response rate was 100 percent of those whom we were able to contact (28 of 32). The average age at interview was 17.2 years. Most patients recalled the operation and denied recollection of pain. Donor-site long-term morbidity was not an issue for 86 percent of patients. Sixty-four percent of patients remembered their preoperative nasal appearance and 89 percent of these preferred the postoperative change and were not concerned with nasal scars or texture. Almost two-thirds of the patients had fixation screws removed from the nasal dorsum because of skin erosion, easy palpability, or visibility. Although several patients expressed a desire to make minor additional changes to their nose, only one of these elected offered presurgical consultation and none have had such surgery. The postoperative nasal appearance compared with that preoperatively was rated as improved for 66.3 percent of responses, 26.5 percent as unchanged, and 7.2 percent as deteriorated. Cantilevered autogenous chondro-osseous rib graft reconstruction of the nasal dorsum is an effective means of reconstruction for the hypoplastic nose in childhood with respect to morphometric measurements, patient self-perception, and the assessment of nasal appearance by others.     

Endoscopically assisted, intraorally approached corrective rhinoplasty.

In the field of facial surgery, operations that require guesswork can result in unexpected complications. One example of such "blind" facial surgery is the lateral osteotomy procedure in corrective rhinoplasty. In most conventional corrective rhinoplasties, the postoperative results of a lateral osteotomy can be controlled by the surgeon's visual perception or manual dexterity; therefore, an experienced surgeon is indispensable in such elaborate operations. Until now, reports have focused on the endoscopic approach through the nasal dorsum or septum through the nostril. However, because of the difficulty in handling the endoscope with osteotomy instruments, it is considered difficult to perform a precise lateral osteotomy procedure using that approach. The authors think the intraoral endoscopic approach should be considered a viable alternative in corrective rhinoplasty.Through small, bilateral gingivobuccal incisions, both the piriform apertures and nasal bones can be easily exposed, and the exact level of the lateral osteotomy can be confirmed directly under the endoscope. The lateral osteotomy is made simply with a reciprocating saw, and symmetrical cutting can be ascertained during the operation. Sometimes, a particular osteotomy level or the proper repositioning of osteotomed segments can be readily evaluated with assistance from the endoscope during the operation. Eleven cases using this procedure were performed over the past 3 years. These endoscopic repairs for a deviated nose were quite helpful for visual confirmation and accurate correction. No complications occurred when using the endoscope with this procedure.     

Aesthetic considerations in nasal reconstruction and the role of modified nasal subunits

In 1985, Burget and Menick's landmark article on the nasal subunit principle popularized the technique of reconstructing the specific topographic subunits that they identified as the dorsum, tip, and columella and the paired alae, sidewalls, and soft triangles. In patients with more than 50 percent of subunit loss, Burget and Menick proposed removing the remaining portion of the subunit and reconstructing the entire subunit with a skin graft or flap. They further supported the placement of incisions for local flaps along borders of aesthetic subunits to maximize scar camouflage. Although the concept of nasal subunits is important in planning the reconstruction, other aesthetic considerations, such as skin texture, color, contour, and actinic damage, are also crucial in achieving an optimal result. Often, focusing on these aspects with the goal of nasal symmetry in mind leads to the violation of the subunit principle but provides a pleasing result of both the defect and the donor site. The purpose of this study was to demonstrate when and how the modification of the nasal subunit principle is used to achieve coverage of nasal skin defects. A retrospective analysis of patients who underwent nasal reconstruction after skin cancer ablation surgery by one surgeon at the Hospital of the University of Pennsylvania from 1987 to 2000 was performed. During this 13-year period, 219 patients underwent 245 nasal reconstructions. Seventy-four patients with 76 reconstructions (31 percent) had procedures that violated the classic nasal subunit principle. Eight of these 74 patients (11 percent) had complications, and eight (11 percent) had 10 revisions performed. The aesthetic and functional results were graded as excellent, good, and fair. The results for the 74 patients who underwent modification of the subunit were excellent in 85 percent, good in 13 percent, and fair in 2 percent. Case reports were selected to illustrate situations in which the nasal subunit was altered.     

Effects of permanent magnets on resting skin blood perfusion in healthy persons assessed by laser Doppler flowmetry and imaging

Effects on skin blood perfusion of permanent ceramic magnets [0.1 T (1000 G) surface field], individually (disk shaped, 4 cm diameter x 1 cm thick) or in the form of a 11 x 7 in pad ( approximately 28 x 17.8 cm) with an array of 16 rectangular magnets (4.5 x 2.2 cm), were investigated in 16 female volunteers (27.4 +/- 1.7 years, range 21-48 years) using three separate protocols. In protocol A, a disk magnet was placed on the palmar surface of the hand in contact with the thenar eminence (n = 5). In protocol B, the magnet was placed on the hand dorsum overlying the thenar eminence (n = 5). In protocol C, the entire palm and fingers rested on the magnetic pad (n = 6). Magnets were in place for 36 min on one hand, and a sham was in place on the other hand. Blood perfusion was measured on the middle finger dorsum by laser Doppler flowmetry (LDF) and on the index finger by laser Doppler imaging (LDI). Perfusion measurements were simultaneously taken in sham and magnet exposed hands, before and during the entire magnet exposure interval. Magnetic field effects were tested by comparing skin blood perfusion sequences in magnet and sham exposed regions. Results showed no significant changes in either LDF or LDI perfusion at magnet or sham sites during exposure, nor were there any significant differences between sham and magnet sites for any protocol. Measurements of skin temperature at the LDF measurement sites also showed no significant change. It is concluded that in the healthy subjects studied with normal, unstressed circulation, magnets of the type and for the duration used, showed no detectible effect on skin blood perfusion in the anatomical area studied.     

Long-term follow-up of nasomaxillary epithelial inlay skin graft for the saddle nose

The nasomaxillary epithelial inlay skin graft described by H. D. Gillies in 1923 is one of the historical procedures of the twentieth century. Nowadays, this method has been thoroughly abandoned, and no long-term follow-up has been reported. In the Tokyo Metropolitan Police Hospital, between 1962 and 1983, 51 patients with saddle nose were treated using this procedure and a specially devised outer prosthesis. A follow-up study of these cases was attempted and that of nine cases was carried out. Six of nine patients have been using the outer prosthesis without any serious complications and are satisfied to varying extent. Three patients underwent further surgical treatment using autografts because of serious complications, which included full-thickness skin necrosis, refractory ulcer of the dorsum of nose, and anxiety about the unphysiological communication between the nasal and oral cavities.     

The role of septal surgery in management of the deviated nose

The deviated nose represents a complex cosmetic and functional problem. Septal surgery plays a central role in the successful management of the externally deviated nose. This study included 260 patients seeking rhinoplasty to correct external nasal deviations; 75 percent of them had various degrees of nasal obstruction. Septal surgery was necessary in 232 patients (89 percent), not only to improve breathing but also to achieve a straight, symmetrical, external nose as well. A graduated surgical approach was adopted to allow correction of the dorsal and caudal deviations of the nasal septum without weakening its structural support to the dorsum or nasal tip. The approach depended on full mobilization of deviated cartilage, followed by straightening of the cartilage and its fixation in the corrected position by using bony splinting grafts through an external rhinoplasty approach.     

Comparability of skin temperatures from three sites on the hand

Skin temperature from three recording sites (web dorsum and two digital sites) on one hand were compared over a 30-minute period during which room temperature was raised from 66 degrees to 80 degrees F causing skin temperatures to range from 78.5 degrees to 92.3 degrees F. The web dorsum remained significantly warmer than either digital site at the lowest skin temperatures; no significant inter-site differences were seen as skin temperature gradually increased. These findings imply that none of the three sites is more advantageous than the others when recording hand temperature values around or above 85 degrees F. However, at the lower levels of skin temperature, there is a "floor" below which the web dorsum is no longer a sensitive indicator. More generally, basic data of this type provide a necessary but often absent foundation for routine practice of clinical biofeedback.     

Nonsurgical correction of nasal deformity in unilateral complete cleft lip: a 6-year follow-up.

Nasal deformity in unilateral cleft lip and palate patients increases with time, tongue malposition being one of the causes. Some authors have emphasized the role of nasal and adjacent facial musculature as active extrinsic agents. Another cause of alar deformity can be the lack of a proper foundation because of a maxillary hypoplasia in the region of the pyriform foramen. If alar collapse occurs, the septum bends convexly toward the cleft side. Tissues are soft and plastic during the neonatal period. Once the infant is about 3 months of age, it becomes difficult to correct the nasal deformity. Therefore, any resource used from the first day, and mainly during the first 15 days of life, will be useful to prevent the increasing deformity and to avoid the surgical correction. A controlled clinical trial was planned to compare the anthropometric measurements of the nasal region in two series of patients with unilateral complete cleft lip. In the first group, we included 44 patients who came to our clinic during the first 2 days of life and the second group consisted of 47 patients who were more than 15 days of age at the time of the first consultation. To provide control data for the evaluation of the results after 6 years of follow-up in both series of cleft patients, we also included a third group of 48 healthy 6-year-old children. A nasal component added to the occlusal prostheses was only used in the first group up to the time of surgery. The same surgeon performed a Millard II procedure with muscular reposition as described by Delaire in all the patients. Nasal measurements taken with a caliper, obtained directly from plaster models by using surface impressions of the babies, were confirmed by a laser three-dimensional measuring device. The statistical comparison between both series showed a significant increase of the columellar length in the first group. A 6-year follow-up to compare growth and cosmetic results of the nose revealed a better and permanent nasal nostril symmetry and no alar cartilage luxation in the patients who had had the nasal component. These results highlight the importance of the early treatment and allow us to suggest the nasal prostheses as a way to prevent the increasing nasal deformity, to help nasal remodeling, to obtain columellar elongation, and to avoid or decrease the need for primary surgery of the cleft nose.     

Surgical correction of the nose and midface in maxillonasal dysplasia (Binder's syndrome)

In 48 patients with maxillonasal dysplasia the retruded nasal base was corrected with onlay cancellous bone grafts after subperiosteal dissection using an oral vestibular approach. Support for the nasal dorsum was achieved in 39 patients with an L-shaped bone graft from the iliac crest introduced through the same approach. The advancement of the nose was found stable on lateral cephalograms; i.e., resorption did not occur. However, the grafts showed considerable remodeling. Half the patients found the stiffness of the nose to be disturbing. In nine patients, the cartilaginous septum was used instead as a support for the nasal dorsum and tip. At operation, the entire cartilaginous septum was mobilized after subperichondrial dissection and rotated forward either pedicled at the nasal dorsum or completely released. Cartilage regenerated in the periochondrial pocket left behind the advanced septum. The anterior transfer of the nose was 6 to 10 mm. The use of septal advancement is preferred over bone implants in the correction of maxillonasal dysplasia in patients in whom the bony nasal dorsum is of adequate height because it results in a soft and flexible nose and the risk of traumatic fracture and resorption is eliminated. The technique has been used in adolescents with promising results.