A problem-oriented and segmental open approach to alar cartilage losses and alar length discrepancies

Alar cartilage losses and alar length discrepancies present problems in nasal tip support, contour, and symmetry. The true extent of the cartilage defect is often not apparent until the time of surgery. This article examines a problem-oriented and segmental open approach to such deformities. It is based on the size of the defect, its location within the dome and lateral crus, and the presence or absence of alar collapse. The defects are classified as major when there is a total or near total loss of the lateral crus, moderate when more than 5 mm is involved, and minor when less than 5 mm is affected. In major defects, a segmental reconstruction of the nasal tip cartilages is undertaken. It consists of a septal graft for columellar support and a conchal shield graft and umbrella graft for nasal tip contour. The whole length of the lateral crus is not reconstructed unless alar collapse is present. In moderate cartilage defects, usually seen laterally in secondary rhinoplasties, the remaining central dome segments are remodeled with shaping sutures. Moderate cartilage length discrepancies, as seen in unilateral cleft lip noses, are equalized through reversed alar rotations. The short crus is rotated laterally, taking length from the medial crus, and the long crus is rotated medially, with the excess advanced into the medial crural footplate. Additional shortening of the long crus can be achieved through cartilage division and advancement. The balanced alar units are then raised with tip projection-vector sutures, and onlay grafts are added if required. In minor cartilage losses, symmetry is usually obtained by shortening the opposite uninjured crus. A total of 33 patients are examined in this review. The average follow-up is 14 months. An improvement in nasal tip shape and support was achieved in all patients.     

A method for repair of cryptotia.

The key points in our method of repair of cryptotia are (1) to cover the skin defect on the posterior aspect of the ear after it is dissected from the head, and (2) to repair the cartilaginous deformity. We describe the use of a temporal skin flap for the former. For the latter, we make parallel incisions on the back of the superior crus and transfer a small graft of conchal cartilage there. The conchal cartilage graft "splints" the repaired crus against cicatricial contracture.     

A modified Goldman nasal tip procedure for the drooping nasal tip

A modification of Irving Goldman's nasal tip procedure that borrows from the lateral crus to augment the height of the medial crus is described. Goldman's procedure has been modified by not including the vestibular skin with the segment of the lateral crus that is rolled medially to increase nasal tip projection, by adding a nasal septal cartilage strut between the medial crura for support when the medial crura are weak, and by maintaining a small separation caudally of the repositioned lateral crura at the new nasal dome to simulate a double nasal dome. This modified Goldman nasal tip procedure allows the surgeon to reshape the lower lateral nasal cartilage to increase nasal tip projection as an alternative to the use of a shield-type nasal tip graft, and at the same time it narrows the nasal tip with minimal resection of the lateral crus of the lower lateral nasal cartilage.     

Secondary correction of the unilateral cleft lip nose using a conchal composite graft

The secondary deformity of the unilateral cleft lip nose has many components. One is the dorsal dislocation of the lateral crus of the alar cartilage. We used a conchal composite graft positioned between the piriform aperture and the lateral crus and the upper lateral cartilage to correct this dislocation in nine patients. We believe that this graft is effective because it elevates the lateral crus of the alar cartilage off the depressed piriform aperture. This technique is very simple to perform, and it is easy to achieve nasal symmetry. Our results have been quite satisfactory, with no recurrence of dorsal dislocation. The donor site was covered by a subcutaneous pedicled flap from the cephaloauricular sulcus, leaving an inconspicuous deformity.     

Anatomy of the Caucasian alar groove

Anatomic studies performed on the noses of 15 cadavers examined the alar groove, alar lobule, and lower lateral crus areas both microscopically and on gross appearance to determine what effect these structures have on overall nasal appearance. In contrast to the findings of previous studies, the authors found the alar lobule to be an area in which dermis is interdigitated with muscle throughout and up to the alar rim. The anteroposterior lengths of the lower lateral crura were again seen to vary in length, presence or absence of accessory cartilages, and shape. Neither corrugation of the posterior elongation nor overlap of the accessory cartilages of the lower lateral cartilage had an effect on phenotype; sharp angles formed by the cartilage were blunted by the layer of fibrofatty muscular tissue between the cartilage and the skin. The alar groove, which lies at the junction of the lower lateral crus (medially) and the alar lobule (laterally), is defined not as much by a muscular attachment between the perichondrium of the lower lateral cartilage and the vestibular mucosa as by a bulging in the fatty layer on one side of the groove (within the cheek, lateral nasal wall, and nasal tip) and a relative paucity of fatty tissue on its other side (within the alar lobule).     

Alar rim deformities

Alar disharmony is one of the most common abnormalities observed after a rhinoplasty. This article describes three classes in addition to Gunter's classifications of alar/columella deformities, which include concave ala, convex ala caused by convex lateral crus, and convex ala caused by thick alar tissues. These deformities are best visualized from the basilar view. The different surgical techniques for correction of true alar abnormalities are presented. The alar convexity, when it is the result of a misshapen cartilage, is corrected using a lateral crura spanning suture, posterior transection of the lateral crura, or transdomal suture. A thick ala, resulting in convexity, can be thinned through either a direct incision on the ala or an incision in the alar base. A lateral crura strut, an onlay graft, or a rim graft eliminates the concavity. For a slight retraction, an alar rim cartilage graft is an optimal choice. For significant alar retractions, the author's preferred technique is an internal V-to-Y advancement, which is described in detail. An elliptical excision of the alar lining will effectively correct the hanging ala. These techniques have been used to correct alar disharmonies on 58 patients. One patient from the V-Y advancement group exhibited a small area of alar necrosis, and two early patients demonstrated an overcorrection; all were easily resolved with revision surgery. By carefully identifying nasal base and alar abnormalities, harmony can be established to correct an undesirable appearance.     

Isolated naso-ocular cleft: a one-stage repair

The naso-ocular cleft is a rare defect; however, isolated alar clefts with or without additional hamartomatous local tissue are an even rarer problem. The authors describe six unilateral and one bilateral cleft patients who were all initially repaired using the same operative procedure. The concept of this procedure is based on the principle that there is basically no soft-tissue deficiency but rather a malpositioning of the parts. The leading edge of the ala is re-created by a rotation advancement of both the medial and the lateral segments adjacent to the cleft. The created secondary defect is filled with a paranasal transposition flap. Three of our patients had hamartomatous excesses and were the most difficult to balance, and at the same time, two of these patients required subsequent bridging or augmentation using a free conchal cartilage graft. Examples of the operative procedures are outlined both schematically and clinically.     

Reconstruction of the nasal tip using nasalis myocutaneous sliding flaps

An alar island subcutaneous sliding flap is described which, when analyzed, is actually myocutaneous, based on the lower portions of the nasalis muscle. In a series of 47 patients, tip defects 1.25 cm in diameter were reconstructed with a unilateral flap, and defects 2.0 cm in diameter were reconstructed with a bilateral flap. The advantage of the flap lies in aesthetics, which are so important in tip surgery. Not only are the incisions at or parallel with the edges of the lateral crus of the lower lateral cartilage, but also chronic edema and "dog-ears" so common after rotation pedicle flaps are avoided.     

The hanging ala

The relationship of the alar rim to the columella can be altered during rhinoplasty. This may be especially true when a long nose has been shortened. In thin-skinned individuals, elevation of the ala may be accomplished by resection of the caudal aspect of the lateral crus without trimming the lining. In thick-skinned individuals, elevation of the ala may be accomplished by resection of the nasal lining at the cephalad border of the alar cartilage.     

Indentation of an osteochondral repair: sensitivity to experimental variables and boundary conditions

The sensitivity of the affects of indenter radius, defect depth, cartilage permeability and flow boundary conditions, on the indentation testing of a repairing osteochondral defect was investigated. Since the boundary condition on the flow across the cartilage repair-subchondral bone interface is not known, the effects of two different conditions were investigated: free-flow and no-flow. A poroelastic finite element model of an osteochondral defect at different stages of the repair process was developed using dimensions typical of the rabbit knee. Results showed when the radius of the indenter was much less than the thickness of the cartilage the sensitivity of the indentation displacement to flow boundary conditions decreased. Simulated indentation displacement was insensitive to bone regeneration up to 50% of the initial defect depth, which suggests that only the properties of the material in the upper-half of the defect are being evaluated. Small variations in permeability had little affect on the simulated indentation. In a fully repaired defect, the simulated indentation is independent of the boundary condition. However, while the defect is in the process of repair and the regenerated cartilage is deeper than the host, indentation is sensitive to the flow boundary condition. Based on these results, and feasible experimental conditions, we conclude that the boundary condition on the repair-subchondral bone interface must be known in all cases except when the defect approaches full repair, if accurate estimates of material properties are to be obtained from indentation.     

非诱导脂肪干细胞膜片复合PRF修复兔髁状突软骨缺损

目的:探索非诱导ADSCs膜片/PRF复合植入物修复兔子下颌骨髁状突软骨缺损的可行性及效果。方法:选取36只3月龄新西兰雄性大白兔,随机分为3个组即ADSCs膜片/PRF组、PRF组、空白对照组,在3%戊巴比妥钠麻醉下解剖暴露出髁状突关节面并用裂钻分别在双侧髁状突软骨面上制备一3 mm直径、3 mm深的髁突表面软骨缺损区,按实验设计每个分组分别填入相应的植入物。分别在术后4周、8周、12周处死相应时间点的动物采集髁突标本,标本进行大体及组织学检查比较。结果:术后12周时空白对照组的下颌髁状突软骨缺损未能修复,PRF组有少量不规则、不连续的软骨形成,ADSCs膜片/PRF组的修复效果较好,表面软骨接近正常纤维软骨,与周围软骨连续性较好。组织学染色也显示ADSCs膜片/PRF组优于PRF组和空白对照组。结论:证明了ADSCs膜片/PRF复合物修复髁状突软骨缺损的可行性。     

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.     

rhBMP-2 诱导异位软骨修复重建兔气管缺损的实验研究

目的:探讨重组人骨形成蛋白-2(rhBMP-2)作为激活物诱导异位软骨修复并重建兔气管缺损的可行性。方法:取24只新西兰大白兔,制备气管前壁软骨1/3缺损模型。随机分为A、B组,每组12只,A组为实验组,在气管缺损处前壁颈前肌肉修补,多点注射rhBMP-2;B组于气管软骨缺损部位直接颈前肌群修补。术后观察动物一般情况,于4、8、12周取材进行大体观察、HE染色观察重建区域情况。结果:术后A组动物均存活至实验完成,B组因气道感染及气道分泌物堵管潴留致使实验兔死亡,其余动物出现皮下气肿,呼吸不畅等情况。组织学观察A组有明显的新生软骨细胞及少量软骨样组织,可见结缔组织包绕,周围肌肉组织完整,排列整齐,未见明显坏死组织,有少量淋巴细胞浸润。B组未见软骨组织生成,可见大量肉芽组织增生,结缔组织排列紊乱,伴少量坏死组织,大量淋巴浸润。结论:rhBMP-2可通过注射到颈前肌肉修补肌群中诱导软骨细胞和软骨样组织生成,减轻炎症反应,联合颈前肌瓣修复重建气管缺损能充分维持修复重建后的气道形态,具有减少术后皮下气肿、气管狭窄的作用,有望用于临床修复重建气管组织缺损。     

Cartilaginous histology of the cleft lip nose: proving the extrinsic etiology

In an effort to prove the etiology of the cleft lip nasal deformity, 23 patients with unilateral cleft lip underwent biopsy through the midportion of the columella from mucosa to mucosa. This tissue "sandwich" contained an internal control of cleft and noncleft medial crus cartilage. With the use of special stains and examination under the microscope at low, medium, and high powers, sections were evaluated on the basis of presence of abnormal chondrocytes, number of binucleate chondrocytes, number of nucleated chondrocytes, number of lacunae, perichondrial thickness, and cartilage thickness. In each specimen examined, there were no significant differences between cleft and noncleft sides, proving histologically the previous subjective observation that the deformity is extrinsic, due to distortion of the lower lateral cartilage by abnormal vectors of force.     

Evaluating osteochondral defect repair potential of autologous rabbit bone marrow cells on type II collagen scaffold

The feasibility of using genipin cross-linked type II collagen scaffold with rabbit bone marrow mesenchymal stem cells (RBMSCs) to repair cartilage defect was herein studied. Induction of RBMSCs into chondrocytic phenotype on type II collagen scaffold in vitro was conducted using TGF-β 3 containing medium. After 3-weeks of induction, chondrocytic behavior, including marker genes expression and specific extracellular matrix (ECM) secretion, was observed. In the in vivo evaluation experiment, the scaffolds containing RBMSCs without prior induction were autologous implanted into the articular cartilage defects made by subchondral drilling. The repairing ability was evaluated. After 2 months, chondrocyte-like cells with lacuna structure and corresponding ECM were found in the repaired sites without apparent inflammation. After 24 weeks, we could easily find cartilage structure the same with normal cartilage in the repair site. In conclusion, it was shown that the scaffolds in combination of in vivo conditions can induce RBMSCs into chondrocytes in repaired area and would be a possible method for articular cartilage repair in clinic and cartilage tissue engineering.     

Suture algorithm for the broad or bulbous nasal tip

The history and current status of suture techniques to correct a broad or bulbous nasal tip are reviewed. General principles for suture techniques to control tip shape are discussed; they include leaving an approximately 6-mm-wide lateral crus. The algorithm presented includes four sutures, all of which are not necessary in every case. These sutures include (1) the transdomal suture (to narrow the individual domes), (2) the interdomal suture (to provide symmetry and tip strength and sometimes to narrow the tip complex), (3) the lateral crural mattress suture (to reduce lateral crural convexity), and (4) the columella-septal suture (to prevent tip drop and adjust tip projection). The lateral crural mattress suture is the newest of these sutures. It specifically controls undesirable convexity of the lateral crus. The four-suture algorithm is principally designed for primary open rhinoplasties. However, it is also recommended for secondary rhinoplasties. A minor modification is suggested for use in closed rhinoplasties. The algorithm is intended to reduce the difficulty of determining which of the currently available rhinoplasty sutures are useful and in what order they should be used. Illustrative cases are provided. The advantages and disadvantages of this particular algorithm, compared with others that have been proposed, are also reviewed.     

Crushed bone grafts and a collagen membrane are not suitable for enhancing cartilage quality in the regeneration of osteochondral defects--an in vivo study in sheep

Hyaline joint cartilage has only a limited potential for self-repair. Some of the published techniques for osteochondral defect therapy try to improve that potential. In this study, it was hypothesised that one of those surgical techniques, the crushed transplanted bone graft together with a collagen membrane, accelerates significantly the reconstruction of the subchondral bone plate and improves the mechanical and histological quality of repaired cartilage in osteochondral defects compared to an empty control defect. In order to test this hypothesis, defects were created in the left knee of 12 sheep and filled either with autologous crushed bone graft or left empty. The animals were sacrificed after 3 (n = 6) and 6 (n = 6) months. No differences were found either macroscopically or histomorphometrically between the bone graft and empty control defects. The biomechanical as well as the histological results of the bone graft defects were inferior to the control defects with inflammatory processes caused either by bone graft or membrane remnants. Based on the results in this sheep model, the filling of subchondral bone defects with compacted cancellous bone should be carefully reconsidered.     

Maturation-dependent spontaneous healing of partial thickness cartilage defects in infantile rats

Partial-thickness articular cartilage defects (PTCDs) do not heal spontaneously and are thought to be a predisposing factor for the development of osteoarthritis. Younger and smaller animals have a better healing capacity for many types of injuries including those to articular cartilage. Our aim was to examine the longitudinal histological changes of immature murine articular cartilage after the creation of small PTCDs and to compare them to PTCDs in mature cartilage. Single linear PTCDs were created in 3-week-old and 16-week-old rats in the direction of joint motion. At 6 and 12?weeks after PTCD creation, histological changes were examined in the defect sites and surrounding cartilage. Immature cartilage showed a higher repair capability than mature cartilage. Although repaired immature cartilage had fibrocartilage, it exhibited better quality than any PTCD model, except for a fetus model and comparable quality to full-thickness cartilage defects (FTCD) after bone marrow stimulation. Elucidation of the underlining mechanisms that immature cartilage possesses for repairing PTCDs is necessary in order to aid the prevention or develop treatment for osteoarthritis.     

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.     

Nasal tip sutures part I: the evolution

Suture techniques for reshaping the nasal tip have been in use for many decades. However, the past two decades have been the most influential in the advancement of the procedures commonly used today. This report details the origin of the major tip suture techniques and tracks their evolution through the years. The early techniques in tip rhinoplasty share a basic principle: the sacrifice of lateral crus integrity to augment the middle and medial crural cartilage to gain tip projection and height. These techniques often disrupt the support mechanisms of the tip lobule, leading to undesirable postoperative results, including supratip fullness, tip asymmetry, tip drop, and an overoperated appearance. Modern nasal tip surgery is founded on the philosophy that suture placement does not simply secure partially excised sections of alar cartilage; rather it aims to directly reshape and reposition the various nasal tip components. The principal suturing methods available in the repertoire of today's rhinoplasty surgeon are the medial crural suture, the middle crura suture, the interdomal suture, the transdomal suture, the lateral crura suture, the medial crura anchor suture, the tip rotation suture, the medial crura footplate suture, and the lateral crura convexity control suture. This report acknowledges past contributions to nasal tip surgery and looks at the recent evolution of techniques commonly used today.