The nasal tip: anatomy and aesthetics.

New anatomic observations and expanded aesthetics are presented based on an in-depth analysis of 50 patients undergoing primary open rhinoplasty. The alar cartilages can be conceived of as three crura (medial, middle, and lateral), each composed of two segments, plus distinct intervening junction points of aesthetic importance. The classic four-dot tip aesthetics can be expanded and wrapped around the nasal lobule in a three-dimensional fashion. Three nasal tip angles are easily defined (angle of tip rotation, angle of domal definition, and angle of domal divergence) and can be created surgically.     

Rhinoplasty: creating an aesthetic tip. A preliminary report

A new approach for creating an anatomically aesthetic nasal tip is presented. It is based on extensive cadaver dissections which demonstrate that a convex domal segment plus a sharp domal segment-lateral crural drop-off are key determinants of a refined tip. This configuration can be achieved with sutures in a manner similar to creating the anthelical curl in an otoplasty. Two operative variations are presented. One achieves tip refinement with a limited increase in projection, while the other provides maximum projection. Currently, the technique is of value in bilateral cleft lip noses, posttraumatic deformities, certain secondary cases, and very selected primary aesthetic cases where tip refinement and projection are limited.     

Mersilene tip implants in rhinoplasty: a review of 98 cases

Reshaping the nasal tip is the most difficult part of a rhinoplasty, particularly in certain types of nasal tip deformities, such as the recessed tip, the thick-skin tip, the boxy tip, the asymmetrical tip, the thin-skin tip, the bifid tip, the turned-up tip, and the turned-down tip. A new approach is introduced regarding the use of Mersilene tip implants. Guidelines for preoperative evaluation and surgical technique are outlined. The so-called "PEPSI" rule (pocket, experience, positioning, shape and size, and incision) is emphasized. The advantages and disadvantages of the Mersilene tip implant are discussed. The Mersilene implant was used in the tip region in a total of 98 patients, and the results are satisfactory.     

Management of the droopy tip: a comparison of three alar cartilage-modifying techniques

The droopy tip is a common nasal deformity in which the tip is inferiorly rotated. Five hundred consecutive rhinoplasty cases were studied to assess the incidence and causes of the droopy tip deformity and to evaluate the role of three alar cartilage-modifying techniques--lateral crural steal, lateral crural overlay, and tongue in groove--in correcting such a deformity. The external rhinoplasty approach was used in all cases. Only one of the three alar cartilage-modifying techniques was used in each case, and the degree of tip rotation and projection was measured both preoperatively and postoperatively. The incidence of droopy tip was 72 percent, and the use of an alar cartilage-modifying technique was required in 85 percent of these cases to achieve the desired degree of rotation. The main causes of droopy tip included inferiorly oriented alar cartilages (85 percent), overdeveloped scrolls of upper lateral cartilages (73 percent), high anterior septal angle (65 percent), and thick skin of the nasal lobule (56 percent). The lateral crural steal technique increased nasal tip rotation and projection, the lateral crural overlay technique increased tip rotation and decreased tip projection, and the tongue-in-groove technique increased tip rotation without significantly changing the amount of projection. The lateral crural overlay technique resulted in the highest degrees of rotation, followed by the lateral crural steal and finally the tongue-in-groove technique. According to these results, the lateral crural steal technique is best indicated in cases with droopy underprojected nasal tip, the lateral crural overlay technique in cases of droopy overprojected nasal tip, and the tongue-in-groove technique in cases where the droopy nasal tip is associated with an adequate amount of projection.     

Analysis of the African American female nose

The African American nose has been broadly classified as ethnic yet it differs significantly in morphology from that of other ethnic groups with which it is categorized. The objectives of this study were to (1) establish an objective protocol for analysis of the African American female nose using anthropometric measurements, and (2) determine whether subjective subcategorization schemes are a reliable replacement for anthropometry. African American women (n = 107) between the ages of 18 and 30 years consented to participate in this study. Photographs and 14 standard anthropometric measurements were taken of the face and nasal region, including nose length, nose width, special upper face height, intercanthal distance, mouth width, nasal bridge inclination, nasal tip protrusion, ala thickness, nasal root width, nasal bridge length, tangential length of ala, length of columella, nasofrontal angle, and nasolabial angle. Nasal indices including nose width-nose height index, nasal tip protrusion-nose height index, and nasal tip protrusion-nasal width index were calculated. In addition, photographic analysis was performed to evaluate nostril shape, nasal base shape, and nasal dorsal height. Proportional relationships and subcategorization schemes were evaluated. A new method of nasal analysis for the African American woman uses the proportional relationships of the anthropometric measurements. Proportional relationships included a columellar to lobule ratio of 1.5:1, a nasolabial angle of 86 degrees, and an alar width to intercanthal distance ratio of 5:4. The nasal dorsal height classification scheme was the most reliable for subjective analysis. The degree of variability found within this group of young African American women is illustrated by the following indices and their respective ranges: nose width-nose height index mean, 79.7 (range, 57 to 102); nasal tip protrusion-nose height index mean, 33.8 (range, 23 to 46); and nasal tip protrusion-nose width index mean, 42.8 (range, 32 to 61). The guidelines provided are a baseline from which to begin analysis and evaluation.     

Rhinoplasty: a simplified, three-stitch, open tip suture technique. Part II: secondary rhinoplasty

Tip suture techniques have proven effective in managing many secondary tip deformities. The open approach is used in most cases because it allows analysis and utilization of the alar remnants. If the alar rim strip is intact and not deformed, then a three-stitch technique (strut, domal creation, and domal equalization) is used. If the domes were previously transected, they are repaired and an attempt is made to shape them with sutures. If sutures are ineffective or the domes are deformed, judicious excisions and tip-shaping sutures are employed to achieve an aesthetic "tip shape," as expressed through the overlying skin. Removal of sutures from previously sutured tips has proven effective in the columella and infralobular area, ineffective in the supratip midline, and unpredictable over the domal segment. Overall, tip suture techniques should be considered in secondary tip deformities whenever the alar cartilage remnants permit.     

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.     

On the effect of parent-aneurysm angle on flow patterns in basilar tip aneurysms: towards a surrogate geometric marker of intra-aneurismal hemodynamics

As a part of previous computational fluid dynamic (CFD) validation studies, particle image velocimetry (PIV) of two anatomically realistic basilar artery tip aneurysm models revealed two distinct types of flow (one of which has yet to be reported in the literature), characterized by the location and strength of the intra-aneurismal vortex. We hypothesized that these distinct "hemodynamic phenotypes" could be anticipated by a simple geometric parameter: the angle of the aneurysm bulb relative to the parent artery. An idealized basilar tip aneurysm model was constructed to allow independent control of this angle, and CFD simulations were carried out for angles ranging from 2 degrees to 30 degrees , these extremes corresponding to the angles measured from the two anatomically realistic models. The gross hemodynamics predicted by the idealized model for 2 degrees and 30 degrees were consistent with those seen in the corresponding anatomically realistic models. For the idealized model, the flow type switched at an angle between 8 degrees and 12 degrees . Sensitivity studies suggested that, near these angles, the hemodynamic phenotype was sensitive to inflow momentum. Outside this range, however, the parent-bulb angle appeared to be a robust predictor of hemodynamic phenotype. Our findings suggest that blood flow dynamics in basilar artery tip aneurysms fall into one of the two broad phenotypes, each subject to distinct hemodynamic forces. That the general features of these flow types may be anticipated by a relatively simple-to-measure geometric parameter could help ease the introduction of hemodynamic information into routine clinical decision-making.     

Primary correction of unilateral cleft lip nasal deformity in Asian patients: anthropometric evaluation

Previously it was thought that primary correction of nasal deformity in cleft lip patients would cause developmental impairment of the nose. It is now widely accepted that simultaneous correction of the cleft lip nasal deformity has no adverse effect on nasal growth. Thus, the authors tried to evaluate the results of primary correction of cleft lip in Asian patients. Of 412 cases of cleft lip, 195 cases were corrected by means of the conventional method from June of 1992 to June of 1997, and 217 cases were corrected by simultaneous rhinoplasty from July of 1997 to October of 2001. The average patient age was 3 months. Photographs and anthropometric evaluation were used to evaluate the results. Nasal tip projection, columellar length, and nasal width were measured in 60 randomized normal children, 30 randomized children treated with the conventional method, and 30 randomized children with primary nasal repair. Data were analyzed using t tests, and the level of significance was 5 percent (p < 0.05). In cases of simultaneous repair, nasal tip projection and columellar length were increased 24.8 percent and 28.8 percent, respectively. Nasal width was increased 12.3 percent in the cases of simultaneous repair and 12.6 percent in the cases without primary rhinoplasty. Simultaneous repair of cleft lip and nasal deformity in Asian patients showed that more symmetry of nostril and nasal dome projection and better correction of buckling and alar flaring were achieved. More balanced growth and development of the alar complex was achieved, and no interference with nasal growth was encountered.     

Binderoid complete cleft lip/palate

A small subset of infants with complete cleft lip/palate look different because they have nasolabiomaxillary hypoplasia and orbital hypotelorism. The authors' purpose was to define the clinical and radiographic features of these patients and to comment on operative management, classification, and terminology. The authors reviewed 695 patients with all forms of incomplete and complete cleft lip/palate and identified 15 patients with nasolabiomaxillary hypoplasia and orbital hypotelorism. All 15 patients had complete labial clefting (5 percent of 320 patients with complete cleft lip/palate), equally divided between bilateral and unilateral forms. The female-to-male ratio was 2:1. Of the seven infants with unilateral complete cleft lip/palate, one had an intact secondary palate and all had a hypoplastic septum, small alar cartilages, narrow basilar columella, underdeveloped contralateral philtral ridge, ill-defined Cupid's bow, thin vermilion-mucosa on both sides of the cleft, and a diminutive premaxilla. Of the eight infants with bilateral complete cleft lip, one had an intact secondary palate. The features were the same as in patients with unilateral cleft, but with a more severely hypoplastic nasal tip, conical columella, tiny prolabium, underdeveloped lateral labial elements, and small/mobile premaxilla. Central midfacial hypoplasia and hypotelorism did not change during childhood and adolescence. Intermedial canthal measurements remained 1.5 SD below normal age-matched controls. Skeletal analysis (mean age, 10 years; range, 4 months to 19 years) documented maxillary retrusion (mean sagittal maxillomandibular discrepancy, 13.7 mm; range, 3 to 17 mm), absent anterior nasal spine, and a class III relationship. The mean sella nasion A point (S-N-A) angle of 74 degrees (range, 65 to 79 degrees) and sella nasion B point (S-N-B) angle of 81 degrees (range, 71 to 90 degrees) were significantly different from age-matched norms ( = 0.0007 and = 0.004, respectively). The ipsilateral central and lateral incisors were absent in all children with unilateral cleft, whereas a single-toothed premaxilla was typically found in the bilateral patients. Several modifications were necessary during primary nasolabial repair because of the diminutive bony and soft-tissue elements. All adolescent patients had Le Fort I maxillary advancement and construction of an adult nasal framework with costochondral or cranial graft. Other often-used procedures were bony augmentation of the anterior maxilla; cartilage grafts to the nasal tip and columella; and dermal grafting to the median tubercle, philtral ridge, and basal columella. Infants with complete unilateral or bilateral cleft lip/palate in association with nasolabiomaxillary hypoplasia and orbital hypotelorism do not belong on the holoprosencephalic spectrum because they have normal head circumference, stature, and intelligence, nor should they be referred to as having Binder anomaly. The authors propose the term cleft lip/palate for these children. Early recognition of this entity is important for counseling parents and because alterations in standard operative methods and orthodontic protocols are necessary.     

Nasal tip sutures part II: the interplays

The achievement of consistently superior results in rhinoplasty is rendered difficult in part by a number of complex interplays between the anatomical structures of the nose and the techniques used for their alteration, such as tip sutures. The effects of sutures depend largely on the magnitude of suture tightening, the intrinsic forces on the cartilages, cartilage thickness, and the degree of soft-tissue undermining. The tip complex is perhaps the most intricate of the nasal structures, exhibiting subtle but evident responses to manipulations of the lower lateral cartilages. The three-dimensional effects of nine suture techniques that are frequently used in nasal tip surgical procedures are discussed and illustrated. (1) The medial crura suture approximates the medial crura and strengthens the support of the tip. The suture also has effects that are less conspicuous immediately. There is slight narrowing of the columella, caudal protrusion of the lobule, and minimal caudal rotation of the lateral crura. (2) The middle crura suture approximates the most anterior portion of the medial crura. There is greater strengthening of the tip and some approximation of the domes with this suture. (3) The interdomal suture approximates the domes and can equalize asymmetric domes. However, the entire tip may shift to the short side if there is a significant difference in the heights of the domes because of short lateral and medial crura. (4) Transdomal sutures narrow the domal arch while pulling the lateral crura medially. The net results are increased tip projection, alar rim concavity, and the potential need for an alar rim graft. In addition, depending on suture position, cephalic or caudal rotation of the lateral crura may be observed. (5) The lateral crura suture increases the concavity of the lateral crura, reduces the interdomal distance, and may retract the alar rims. Perhaps the most significant inadvertent results of this suture are caudal rotation of the tip and elongation of the nose. This is important because patients who undergo rhinoplasty would often benefit from cephalic, rather than caudal, rotation of the tip. (6) The medial crura-septal suture not only increases tip projection but also rotates the tip cephalically and retracts the columella. (7) The tip rotation suture shifts the tip cephalad while retracting the columella. (8) The medial crura footplate suture approximates the footplates, narrows the columella base, and improves undesirable nostril shape. (9) The lateral crura convexity control suture alters the degree of convexity of the lateral crura. The nuances of these sutures and their multiplanar effects on the nasal tip are discussed.     

Rhinoplasty: a simplified, three-stitch, open tip suture technique. Part I: primary rhinoplasty

Tip suture techniques offer a reliable and dramatic method of tip modification without needing to interrupt the alar rim strip or add tip grafts. The present simplified three-stitch technique consists of the following: (1) a strut suture to fix the columella strut between the crura, (2) bilateral domal creation sutures to create tip definition, and (3) a domal equalization suture to narrow and align the domes. If required, columella septal sutures can be added; either a dorsal rotational suture or a transfixion projection suture can be used. This simplified method represents a refinement based on more than 13 years of experience with tip suture techniques. It does not require a complex operative sequence or specialized sutures. Primary indications are moderate tip deformities of inadequate definition and excessive width and certain specific tip deformities, including the parenthesis tip and nostril/tip disproportion. The primary contraindications are for patients with minor tip deformities that are best done through a closed approach and those with severe tip deformities requiring an open structure graft. The technique is simple, efficacious, and easily learned.     

Nasal vestibule wall elasticity: interactions with a nasal dilator strip.

We studied the effect of an adhesive external nasal dilator strip (ENDS) on external nasal geometry in 20 healthy Caucasian adults (10 men, 10 women; age 21-45 yr). The recoil force exerted by ENDS was estimated by bending the device (n = 10) with known weights. In the horizontal direction, a small/medium-sized ENDS in situ exerted a unilateral recoil force of 21.4-22.6 g. Application of ENDS resulted in a displacement of the lateral nasal vestibule walls that had both anterosuperior and horizontal components and that was maintained over an 8-h period. The resultant unilateral nasal vestibule wall displacement at the tip of the device was at 47.6 +/- 2.0 degrees to the horizontal (as related to the plane of the device when in situ) and had a magnitude of 3.5 +/- 0.1 mm. ENDS increased external nasal cross-sectional area by 23.0-65.3 mm2. Nasal vestibule wall compliance was estimated at 0.05-0.16 mm/g. Thus ENDS applies a relatively constant abducting force irrespective of nasal width. Variable responsiveness to ENDS may be related to differences in elastic properties of the nasal vestibule wall.     

Primary correction of the unilateral cleft nasal deformity

An 18-year experience with the management of the unilateral cleft nasal deformity in 1200 patients is presented. A primary cleft nasal correction was performed at the time of lip repair in infancy; a secondary rhinoplasty was done in adolescence after nasal growth was complete. The technical details of the authors' primary cleft nasal correction are described. Exposure was obtained through the incisions of the rotation-advancement design. The cartilaginous framework was widely undermined from the skin envelope. The nasal lining was released from the piriform aperture, and a new maxillary platform was created on the cleft side by rotating a "muscular roll" underneath the cleft nasal ala. The alar web was then managed by using a mattress suture running from the web cartilage to the facial musculature. In 60 percent of cases, these maneuvers were sufficient to produce symmetrical dome projection and nostril symmetry. In the other 40 percent, characterized by more severe hypoplasia of the cleft lower lateral cartilage, an inverted U infracartilaginous incision and an alar dome supporting suture (Tajima) to the contralateral upper cartilage were used. Residual dorsal hooding of the lower lateral cartilage was most effectively managed with this suture. This primary approach to the cleft nasal deformity permits more balanced growth and development of the ala and domal complex. Some of the psychological trauma of the early school years may be avoided. Also, because of the early repositioning of the cleft nasal cartilages, the deformity addressed at the time of the adult rhinoplasty is less severe and more amenable to an optimal final result.     

Maxillary advancement for mandibular prognathism: indications and rationale

The surgical correction of mandibular prognathism has traditionally involved posterior repositioning of the mandibular body. This treatment approach corrects the skeletal disproportion at the expense of reducing facial skeletal volume and can unpredictably result in inadequately supported soft tissues with loss of skeletal definition. In an effort to avoid these sequelae of mandibular reduction, 18 patients diagnosed as having mandibular prognathism were treated with maxillary advancement surgery at the Le Fort I level. Mean patient SNB angle was 85.2 degrees, as compared with a normal 79 +/- 3 degrees. Maxillae were documented to be in normal position relative to both cranial base and Frankfort horizontal. The mean maxillary advancement was 6.9 mm, with a range of 4.5 to 8.8 mm. All patients required genioplasty to reduce vertical chin height and/or to laterally shift the chin. At the time of follow-up (mean 16.2 months), all patients retained cephalometric data suggestive of enlarged mandibles and excessive anterior facial divergence. However, maxillomandibular harmony and facial convexity had been restored without sacrificing skeletal volume. Treatment results demonstrated these faces to be skeletally well proportioned despite lower face protrusion that was beyond "normal." Postoperative appearances were characterized by a well-supported soft-tissue envelope and a highlighted skeletal foundation, creating angular, well-defined lower faces. These findings support the credibility of maxillary advancement as the procedure of choice in selected individuals with mandibular prognathism. Indications and an aesthetic rationale for this surgical approach are presented.     

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.     

The two essential elements for planning tip surgery in primary and secondary rhinoplasty: observations based on review of 100 consecutive patients

Nasal tip surgery has become significantly more complex since the introduction of tip grafting and the many suture designs that followed the resurgence of open rhinoplasty. Independent of the surgeon's technical approach, however, is the need to identify the critical anatomical characteristics that will make nasal tip surgery successful. It is the author's contention that only two such features require mandatory preoperative identification: (1) whether the tip is adequately projecting and (2) whether the alar cartilage lateral crura are orthotopic or cephalically rotated ("malpositioned"). Data were generated from a review of 100 consecutive primary rhinoplasty patients on whom the author had operated. The results indicate that only 33 percent of the entire group had adequate preoperative tip projection and only 54 percent had orthotopic lateral crura (axes toward the lateral canthi). Forty-six percent of the patients had lateral crura that were cephalically rotated (axes toward the medial canthi). Both inadequate tip projection and convex lateral crura were more common among patients with malpositioned lateral crura (78 percent and 61 percent) than in patients with orthotopic lateral crura (57 percent and 20 percent, respectively). Tip projection can be reliably assessed by the relationship of the tip lobule to the septal angle. Malposition is characterized by abnormal lateral crural axes, long alar creases that extend to the nostril rims, alar wall hollows, frequent nostril deformities, and associated external valvular incompetence. The data suggest that the surgeon treating the average spectrum of primary rhinoplasty patients will see a majority (61 percent) who need increased tip support and a significant number (46 percent) with an anatomical variant (alar cartilage malposition) that places these patients at special risk for postoperative functional impairment. Correction of external valvular incompetence doubles nasal airflow in most patients. As few as 23 percent of primary rhinoplasty patients (the number with orthotopic, projecting alar cartilages in this series) may be proper candidates for reduction-only tip procedures. When tip projection and lateral crural orientation are accurately determined before surgery, nasal tip surgery can proceed successfully and secondary deformities can be avoided.     

The conflicting requirements of laxity and conformity in total knee replacement

Bearing surfaces of total condylar knees which are designed with a high degree of conformity to produce low stresses in the polyethylene tibial insert may be overconstrained. This study determines femoral and tibial bearing surface geometries which will induce the least destructive fatigue mechanisms in the polyethylene whilst conserving the laxity of the natural knee. Sixteen knee designs were generated by varying four parameters systematically to cover the range of contemporary knee designs. The parameters were the femoral frontal radius (30 or 70 mm), the difference between the femoral and tibial frontal radii (2 or 10 mm), the tibial sagittal radius (56 or 80 mm) and the posterior-distal transition angle (-8 or -20 degrees), which is the angle at which the small posterior arc of the sagittal profile transfers to the larger distal arc. Rigid body analyses determined the anterior-posterior and rotational motions as well as the contact points during the stance phase of gait for the different designs. In addition, a damage function which accumulated the fluctuating maximum shear stresses was used to predict the susceptibility to delamination wear of the polyethylene (damage score). This study predicted that of the 16 designs, the knee with a frontal radius of 70 mm, a difference in femoral and tibial frontal radii of 2 mm, a tibial sagittal radius of 80 mm and a posterior distal transition angle of -20 degrees would satisfy the conflicting needs of both resistance to delamination wear and natural kinematics.     

In vivo estimation of contraction velocity of human vastus lateralis muscle during "isokinetic" action.

To determine the shortening velocities of fascicles of the vastus lateralis muscle (VL) during isokinetic knee extension, six male subjects were requested to extend the knee with maximal effort at angular velocities of 30 and 150 degrees /s. By using an ultrasonic apparatus, longitudinal images of the VL were produced every 30 ms during knee extension, and the fascicle length and angle of pennation were obtained from these images. The shortening fascicle length with extension of the knee (from 98 to 13 degrees of knee angle; full extension = 0 degrees ) was greater (43 mm) at 30 degrees /s than at 150 degrees /s (35 mm). Even when the angular velocity remained constant during the isokinetic range of motion, the fascicle velocity was found to change from 39 to 77 mm/s at 150 degrees /s and from 6 to 19 mm/s at 30 degrees /s. The force exerted by a fascicle changed with the length of the fascicle at changing angular velocities. The peak values of fascicle force and velocity were observed at approximately 90 mm of fascicle length. In conclusion, even if the angular velocity of knee extension is kept constant, the shortening velocity of a fascicle is dependent on the force applied to the muscle-tendon complex, and the phenomenon is considered to be caused mainly by the elongation of the elastic element (tendinous tissue).