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BACKGROUND Closure of the nasal skin defects that resulted from excision of the skin neoplasms represents a challenging problem in reconstructive surgery. Here, the use of the reading man procedure as a new alternative in reconstruction of the skin defects of the nose is presented. MATERIALS AND METHODS In this procedure, 2 local flaps designed in an unequal Z-plasty manner are used. Defect coverage is achieved by transposing the first flap to the defect area, whereas the second flap is used for closure of the first flap's donor site. In last 10 years, this technique has been used for closure of the nasal skin defects that resulted from removal of skin cancers in 28 patients (15 men and 13 women) aged from 45 to 98 years. The defects were ranging between 1.5 and 3.1 cm in diameter. RESULTS In all patients, a tension-free 1-stage closure was obtained. There was no patient with dog ear formation and/or distortion of the mobile anatomical structures, such as nasal tip, alar lobules, and nostrils. All patients healed without complications. A mean follow-up of 52 months (8 months to 6.5 years) revealed satisfactory cosmetic results in all patients. No tumor recurrence was observed. CONCLUSIONS Using the advantage of extra tissue relaxation provided by an unequal Z-plasty, the reading man procedure seems to be a useful alternative for the closure of nasal defects with alike local skin. As a critical achievement, this procedure does not require excision of additional healthy tissue. Borrowing tissue from multiple directions, it avoids dog ear formation and distortion of the mobile anatomic structures.

Correcting a secondary bilateral cleft lip nasal deformity is very complex with many challenges due to its complexity. This study presents the surgical results after correcting a secondary bilateral cleft lip nasal deformity using isolation and repositioning of the lower lateral cartilages, the columellar strut, and an onlay graft on the nasal tip.Eighteen patients who had bilateral cleft lip nasal deformities and who had surgery performed between September 2013 and December 2019 were included in this study. The age of the patients ranged between 19 and 52 years. Open rhinoplasty with bilateral reverse-U incision was performed. The lower lateral cartilages were isolated and repositioned. Nasal tip support is provided using a columellar strut with a septal cartilage or Medpor strut. In the vertical component of the nasal tip, a conchal cartilage graft was used. The mean follow-up period was 2 years (ranging from 1 to 6 years).Fourteen of the 18 patients underwent photogrammetric evaluation. After surgery, the projection of the nasal tip and angle increased, but nasal bridge length decreased. The columella-labial angle significantly increased by 10.1% after surgery which was statistically significant (P 0.05). The angle between the nostril axes significantly decreased by 46.2% postoperatively and also reached statistical significance (P 0.05), indicating that the displaced alar base and lower nostril sill improved and the major axis of the nostril changed more vertically oblique. All patients were pleased with their surgical results.The proposed technique was highly effective in correcting secondary bilateral cleft lip nasal deformities in adults.

The authors present their experience using "Lateral Crural Steal" (LCS) and "Tongue in Groove" (TING) techniques in nasal tip remodeling.The paper aimed to evaluate the efficacy and safety of the use of LCS and TING in nasal tip remodeling for aesthetic improvement.A randomized controlled trial was conducted. Thirty-five patients affected by low and boxy nasal tips were treated with LCS and TINGs (study group [SG]), comparing results with the control group (CG) (n = 30) treated with cartilage grafts. The preoperative analysis has been performed with an accurate clinical evaluation, a photographic assessment, and a computed tomography scan. Postoperative follow-up took place at 1, 2, and 4 weeks, 3, 6, and 12 months, and then annually.A total of 82.9% (n = 29) of SG patients showed excellent cosmetic and functional results after 1 year compared with the CG patients, who showed the same results in only 40% (n = 12) of cases. The tip projection maintenance and contour restoring in the SG were higher than that in the CG ( P 0.0001 versus CG).The use of LCS and TING was safe and effective in this series of cases performed.

SUMMARY The intermediate cleft tip rhinoplasty is frequently performed during childhood to address nasal tip anomalies in cleft patients before the most critical period of psychosocial development. The authors previously described the component restoration intermediate cleft tip rhinoplasty technique for the unilateral cleft nose, which was developed to systematically address the lining deficiency, cleft lower lateral cartilage malpositioning, and cleft lateral cartilage weakness using a combination of lower lateral cartilage release, lateral cartilage repositioning, and placement of an auricular composite chondrocutaneous graft. In this work, the authors evaluate the utility of this technique to the bilateral cleft nose. Preoperative and postoperative (mean ± SD, 18.6 ± 10.8 months) photographs of bilateral cleft patients treated with the component restoration intermediate cleft tip rhinoplasty (n = 7) were evaluated using photogrammetric measurements and aesthetic assessments. From preoperatively to postoperatively, the columella length-to-alar width ratio on basal photographs increased (0.19 ± 0.05 versus 0.28 ± 0.05; p = 0.001). On lateral view, the columella-labial angle decreased from preoperatively to postoperatively [138 degrees (interquartile range, 132 to 144 degrees) versus 123 degrees (interquartile range, 122 to 139 degrees); p = 0.04]. Aesthetic ratings performed by four blinded observers also improved from preoperatively to postoperatively (1.6 ± 0.8 versus 2.4 ± 0.7; p = 0.004). As a comparison, bilateral cleft nose patients who did not undergo intermediate cleft tip rhinoplasty (n = 3) of similar ages were subjected to the same photogrammetric and aesthetic analyses, which showed no differences from preoperatively to postoperatively. In combination, the current work suggests that the component restoration technique in the bilateral intermediate cleft tip rhinoplasty improves nasal tip support and aesthetic outcomes.

Nasal tip plasty is a surgery that determines important rhinoplasty outcomes. A variety of autologous and alloplastic implants are utilized in this procedure, including 1 synthetic material known as polycaprolactone (PCL). This study provides background on the ready-made three-dimensional printed PCL implant for nasal lobule correction, before discussing the usefulness and effectiveness of the implant. A total of 23 patients who visited our hospital between January 2018 and January 2020 were evaluated in this study. We used 3 types of PCL implant to get an ideal shape for the nasal tip: tipball (globular shape), droneball (rugby ball shape), and dumbbell (dumbbell shape). The authors compared nasolabial angle and tip projection at the preoperative and postoperative period via photographic anthropometric analysis. In 4 patients, we also examined the dead space between the implant and soft tissue via ultrasonography. The follow-up period averaged 9.5 months and no serious complications were found after surgery. The nasolabial angle and tip projection had an average postoperative increase of 6.4° and 0.044, respectively. Ultrasonography revealed the attachment of the implant at the insertion site and no dead space was found. This is the first attempt to apply a ready-made three-dimensional printed PCL implant to a nasal lobule correction procedure. As the implant was easy to use and showed good results, it may be useful for aesthetic purposes in future nasal tip plasty procedures.

Rhinoplasty to reshape the nasal tip is increasingly popular among Chinese women. Aesthetic standards vary across different ethnic groups and it is key to identify preferences for the ideal nasal tip in China to set surgical goals. Therefore, we administered an online survey to plastic surgeons and the public through social media to rank nasal tip images by aesthetic preference. Images were created from a single photograph to show various dimensions of nasal tip projection to nasal dorsum length ratio (NTP/NDL) and nasal labial angle (NLA). Preferences were compared by age, sex, living area, ethnic background, occupation, and history of plastic procedures on respondents' preferences. Overall, there were 703 respondents, including 441 (63%) women and 50 plastic surgeons. Nasal tip projection to nasal dorsum length ratio of 0.63 was ranked highest by all demographic groups, including women (47%), men (50%), and plastic surgeons (66%). Nasal labial angle of 106° was first choice overall and preferred by 34%, 34%, and 52%, respectively. Preferences followed a bell curve for NTP/NDL and NLA, with lower rates of preference as parameters diverged further from the first choice. The preference for NTP/NDL of 0.63 and NLA of 106° was conserved across surgeons, lay people, and all demographic groups. The authors suggest that these proportions could be used as reference for preoperative design in rhinoplasty.

SUMMARY Nasal tip deprojection is a common goal in rhinoplasty. Several techniques have been described, many of which require destructive techniques that compromise the intrinsic integrity and morphology of the lateral crura. Through lateral translocation of the domes and shortening of the medial crura, nasal tip deprojection can be achieved without disrupting the integrity of the lateral crura. The domes are recreated lateral to the intrinsic domes with a standard transdomal suture, and excess length of the middle and medial crura is managed through transection and shortening of the medial crura. This technique preserves the morphology of the nasal base without altering the position of the medial crural footplates. Deprojection of 4 to 5 mm can be readily achieved with this technique.

BACKGROUND Le Fort I maxillary repositioning influences nasal morphology. In Asian cultures, upward nasal tip rotation with increased nostril exposure is considered aesthetically unpleasant and can have psychosocial consequences. This three-dimensional imaging-based study evaluated the effect of different Le Fort I maxillary movements on nasal tip rotation. METHODS Consecutive patients who underwent two-jaw orthognathic surgery (n = 107) were enrolled. To achieve a standard head orientation, preoperative and 1-week and 12-month postoperative cone-beam computed tomography-derived three-dimensional craniofacial models were superimposed. Tip rotation angle was calculated according to the Frankfort horizontal plane for all three-dimensional digital models. The final tip rotation angle change was defined as 12-month postoperative value minus preoperative value. Translational maxillary movement types (advancement versus setback and intrusion versus extrusion), postoperative maxillary segment locations (anterosuperior, anteroinferior, posterosuperior, or posteroinferior), and actual linear maxillary changes were noted. RESULTS Advancement (1.79 ± 5.20 degrees) and intrusion (2.23 ± 4.96 degrees) movements demonstrated significantly larger final tip rotation angle changes than setback (-0.88 ± 5.15 degrees) and extrusion (0.09 ± 5.44 degrees) movements (all p < 0.05). Postoperative anterosuperior location (2.95 ± 4.52 degrees) of the maxillary segment demonstrated a significantly larger final tip rotation angle change than anteroinferior (0.48 ± 5.65 degrees), posterosuperior (-1.08 ± 4.77 degrees), and posteroinferior (-0.64 ± 5.80 degrees) locations (all p < 0.05). Translational maxillary movement and actual linear maxillary change were not correlated with final tip rotation angle change. CONCLUSION Effects of Le Fort I maxillary repositioning on nasal tip rotation depend on movement types and maxillary segment location. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Dermoid cyst is a congenital and benign disease with most occur on the head and neck. It is rarely that occur on the nasal tip and nasal septum at same time and rarely repair of using nasal septum mucosa. The authors treated a child with dermoid cyst in the nasal tip and septum. Only the dermoid cyst at the tip of the nose caused the change of appearance. Dermoid cyst of nasal septum did not cause any clinical symptoms. She underwent excision of the dermoid cyst at the tip of the nose and endoscopic surgery for the dermoid cyst in the nasal septum and used the nasal septum mucosa for repair at the same time. After 6 months of recovery, the appearance of the nasal tip recovered well without obvious scar, the nasal septum area recovered well, and the local stoma was unobstructed without recurrence. The authors found that this kind of nasal septal cyst with no clinical symptoms can achieve good therapeutic effect through endoscopic surgery and repair of using nasal septum mucosa, with less damage, rapid recovery, and good prognosis.

The autologous conchal cartilage of good elasticity is easy to harvest, thus is often used in nasal tip plasty of East Asians. However, the operation techniques vary a lot among different surgeons. This article aims to introduce 3 techniques commonly used in clinical practice.One hundred three patients were included in this study and divided into 3 groups according to the shape of the nasal tip during 2017 to 2019. The patients were followed up for at least 6 months. All patients were measured with Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS). ImageJ software was used to measure and calculate the projection ratio for lateral position standard image, and columella-labial angle (CLA) was measured.In group 1, SCHNOS for nasal obstruction (SCHNOS-O) score were 13.23 ± 7.61 and 14.49 ± 10.55 (P0.05); SCHNOS for nasal cosmesis (SCHNOS-C) score were 66.55 ± 31.23 and 21.73 ± 18.91 (P0.001); projection ratio were 0.51 ± 0.04 and 0.57 ± 0.05 (P0.001); CLA were 91.02° ± 5.67° and 93.55° ± 4.64° (P0.05), preoperative and postoperative, respectively. In group 2, SCHNOS-O score were 16.76 ± 13.44 and 15.44 ± 9.26 (P0.05); SCHNOS-C score were 61.87 ± 44.14 and 19.16 ± 29.37 (P0.001); projection ratio were 0.50 ± 0.05 and 0.58 ± 0.03 (P0.001); CLA were 92.32° ± 6.39° and 94.86° ± 5.96°(P0.05), preoperative and postoperative, respectively. In group 3, SCHNOS-O score were 15.25 ± 7.83 and 17.73 ± 11.66 (P0.05); SCHNOS-C score were 52.03 ± 33.38 and 17.73 ± 11.66 (P0.001); projection ratio were 0.53 ± 0.05 and 0.57 ± 0.02 (P0.001); CLA were 91.65° ± 5.75° and 93.21° ± 5.38° (P0.05), preoperational and postoperational, respectively.None of these 3 techniques cause or aggravate nasal obstruction, and all of them can achieve high cosmetic satisfaction. Technique 1 and technique 2 are suitable for the patients with moderate and moderate to severe short nose that is common in East Asia, which can better increase the protrusion of the tip and length of the nose. Technique 3 is suitable for the patients with better shape of the nose, who need to slightly increase the protrusion of the nasal tip and increase the upward rotation.

AIM To evaluate the contribution to patient satisfaction of the newly reshaped topographic anatomy of the nose, demographic, and functional results in the postoperative period of septorhinoplasty surgery. METHOD A total of 370 patients applied with open and closed septorhinoplasty techniques for various reasons were grouped according to the postoperative Rhinoplasty Outcome Evaluation (ROE) Scale results; Group 1 (open rhinoplasty satisfied group, ROE ≥12 points, n:194), Group 2 (open rhinoplasty dissatisfied group, ROE

Effective control of nasal tip projection and rotation is a key component in modern rhinoplasty. Tip projection is a product of several anatomical factors: length and strength of lower lateral cartilages, the suspensory ligament, fibrous connections to the upper lateral cartilages, and the anterior septal angle. Several cartilage grafts have been described for effectively altering nasal tip projection and rotation. Columellar struts and septal extension grafts are both commonly used in modern rhinoplasty to affect projection and rotation of the nasal tip. Although columellar strut grafts have shown moderate efficacy in maintaining tip projection and unifying the tip complex, their effect on increasing tip projection has been shown to be very limited. In comparison, septal extension grafts have been shown to effectively control tip projection, rotation, and shape by securing the nasal tip to the septum. Varieties of septal extension grafts have been described to support the medial crura and control tip shape, all of which depend on the presence of a stable caudal septum. The type of graft used is dependent on the specific characteristics of the underlying tip structures. The authors' aim is to provide an updated classification of cartilage grafts for altering nasal tip projection and rotation, and an algorithmic approach for their implementation. Although both columellar struts and septal extension grafts offer the modern rhinoplasty surgeon a way to alter tip projection and rotation, they do vary in efficacy. Understanding which graft to use and in what setting is key in successfully controlling projection, rotation, and shape of the nasal tip.

Background Control and maintenance of nasal tip position are critical in rhinoplasty. Two frequent methods of exerting tip control are columellar strut and caudal septal extension graft. However, no quantitative data exist comparing the two methods over time. The purpose of this study was to analyze maintenance of tip projection and rotation following either columellar strut or septal extension graft. Methods A retrospective cohort study of patients undergoing rhinoplasty was reviewed. Three-dimensional photogrammetric evaluation of patients with either columellar strut or septal extension graft to increase tip projection was performed. Anthropometric points were analyzed in a blinded fashion. Outcome variables were tip projection, nasal length, the Goode ratio, and tip rotation. Results were stratified based on technique and compared statistically. Results One hundred six patients were included. Overall, 66 percent were female, with an average age of 34.5 years. A columellar strut was used in 42 percent of cases (n = 45), and a septal extension graft was used in 57 percent (n = 61). Analysis showed greater maintenance of tip rotation over time with the septal extension graft compared with the columellar strut [-1.01 percent change (p = not significant versus -5.08 percent change (p = 0.009)]. Tip projection, nasal length, and the Goode ratio decreased over time for both groups, but the differences were not statistically different. Conclusions Nasal tip projection and rotation appear to decrease from the immediate postoperative position. In this study, both septal extension graft and columellar strut exhibit similar changes in tip projection with time; however, septal extension graft is better able to preserve tip rotation compared with the columellar strut. Clinical question/level of evidence Therapeutic, III.

The nasal tip projection and rotation to be obtained with tip plasty play a key role in achieving successful results. Cartilage sparing techniques provide extra ease to reshape the cartilage in revision rhinoplasty. Freed dome cartilage eliminates the restricting forces of mucosa. The authors recommend to free the dome cartilage from mucosa during the tip plasty which ensures the desired dome shape and extra projection. A total of 218 patients who were operated between the dates of January 2017 and August 2018 were included in this study. About 3 mm parts of the marked domes toward medial and lateral crurae were dissected from the mucosa. New domes were created with bilateral hemitransdomal sutures. The outcome of the operation was asked to the patients verbally and answers were recorded. Of 218 patients who were included in the study, 182 were females and 36 were males. Patients had a mean age of 26.5 years. The length of follow-up was 11.8 months. About 205 patients had primary rhinoplasty while 12 patients had secondary rhinoplasty and 1 patient had revision rhinoplasty. Of the patients, 89.9% (196/218) were very satisfied with the result and 7.4% (16/218) were satisfied, whereas 2.7% (6/218) were dissatisfied. Only 5 patients who were dissatisfied with the result underwent revision rhinoplasty operation. The combination of the modified free dome suture with the mucosal dissection in dome area provides achieving the desired tip projection and symmetry.

Background Middle crura support deficiency and short middle crura can usually cause insufficient definition and projection of the tip and can sometimes result in a flat tip. The aim of this study was to investigate the effectiveness of a new technique involving a tip reinforcement flap to strengthen the middle crura and to achieve a well-projected and defined tip. Methods Twenty-nine patients who underwent primary open-approach rhinoplasty that included the use of tip reinforcement flaps were included in the study. Cartilage flaps that had been created from the excess cephalic portion of the lateral crura were prepared as medial crura-based cartilaginous flaps. Results There were 29 patients (17 women, 12 men) aged 18 to 44 years (mean age, 31 years). Follow-up time ranged between 3 and 25 months (mean, 21 months). Preoperative and postoperative average of nasal tip length was 10.84 (±1.07) mm and 14.32 (±2.34) mm, respectively (P = 0.0214). Preoperative and postoperative average of nasolabial angle was 97.42° (±9.84°) and 107.99° (±12.16°), respectively (P = 0.0344). Preoperative and postoperative average of nasal projection ratio was 0.53 (±0.04) and 0.57 (±0.03), respectively (P = 0.4347). The tip reinforcement flap technique provided strengthening and extra support for the middle crura and increased definition, projection, and stability to the domal area. Conclusions The tip reinforcement flap technique offers advantages for tip plasty in those cases with middle crural deficiency, short middle crura, and middle crural weakness. The technique also provides an additional projection, stabilization, and definition to the nasal tip while reducing lateral crural cephalic excess. This technique improves nostril-lobular disproportion and has the advantage of hiding extra support grafted into the folded flap. Complications such as graft visibility, malposition, and asymmetry, which may occur with the use of classic tip grafts, can be eliminated with the tip reinforcement flap technique.

INTRODUCTION This study aimed to evaluate postsurgical changes of nasal tip and lateral nostril characteristics after semi-tongue-in-groove (TIG) technique in open rhinoplasty surgery. MATERIALS AND METHODS This prospective observational study was performed in a before-after setting on 22 patients who underwent open rhinoplasty surgery using semi-TIG technique. Postoperative photographs were analyzed for nasal tip and lateral nostril changes at several time points (1, 4, and 12 weeks after surgery) and were compared with preoperative photographs. Nasal tip support change after the surgery was also assessed using a purpose-designed device. RESULTS In total, 22 patients were studied (20 females, 2 males). The tip support increased by 98%, 291.8%, and 377% at certain time points after the surgery. The tip rotation increased significantly at all measuring time points, postoperatively. The length of upper lip increased at all time points after semi-TIG technique. Columellar show and nostril length and height decreased significantly after the surgery. CONCLUSION The characteristics of the nasal tip and lateral nostrils along with nasal tip support showed significant improvement after the semi-TIG technique. Therefore, this technique is recommended in selected rhinoplasty cases to achieve more favorable objective results.

BACKGROUND Although columellar strut grafts (CSGs) are considered among the fundamental steps for providing nasal tip support, a downward rotation of the nasal tip in patients with strut grafts can still be encountered. Patient-related factors such as nasal skin thickness can allow the plastic surgeon to anticipate certain drawbacks that can be encountered in the healing phase, but patient-based differences of nasal cartilage and the resulting impact have yet to be investigated. The purpose of this study was to evaluate the effect of the biomechanical properties of CSGs on late postoperative nasal tip position and support. METHODS The study was undertaken with the participation of 20 patients undergoing closed-technique primary rhinoplasty with CSGs. Each cartilage specimen was biomechanically analyzed to calculate the modulus of elasticity. Preoperative and postoperative images were obtained to determine nasal tip position and rotation with quantitative measurements. Postoperative 3- and 12-month measurements were evaluated according to their relationship with the elasticity modulus of the utilized cartilages. RESULTS The evaluation demonstrated that the elasticity modulus can impact the long-term support of the nasolabial angle in which an increase in the coefficient of elasticity can result in a decrease in long-term nasal tip support. CONCLUSION The results of the study reveal a new objective variable that can impact nasal tip dynamics and patient-related differences following rhinoplasty. This study not only brings forth a different perspective in the evaluation of nasal tip dynamics but can also provide data for determining ideal values for cartilage prefabrication.

Background:The objective of this study was to illustrate a novel technique for lifting of the aging upper lip with nasal tip plasty in Asians. With this procedure, a shortening of the philtrum, an increase of the vermilion, and a natural and nicer mouth can be obtained, with increase of the tip of t

Background The intermediate cleft tip rhinoplasty is performed in childhood to address residual tip asymmetries during the most critical period of psychosocial development. The authors describe and evaluate long-term outcomes of that approach for the unilateral cleft lip and palate patient based on the concept of individual restoration of each abnormal anatomical component. Methods Photomorphometric analyses of unilateral cleft lip and palate patients (n = 50) who underwent intermediate cleft tip rhinoplasty using the component restoration technique were evaluated preoperatively (time 0) and postoperatively at less than 1 year (time 1), 1 to 3 years (time 2), and more than 3 years (time 3) and compared to age-matched unilateral cleft lip and palate control patients. Nasal relationships (alar symmetry, nasal tip protrusion-to-alar base width ratio, and height-to-width dimensions for the cleft and noncleft nostrils) were compared over time using a linear mixed-effect model. Results At time 0, both groups demonstrated similar nasal relationships, with the exception of a wider cleft-side nostril in relationship to height in the rhinoplasty group. The component restoration technique improved all four nasal relationships at all postoperative time points compared with time 0 in a statistically significant manner, whereas control patients did not demonstrate significant changes at the corresponding ages. Long-term differences at time 3 revealed a trend toward improved alar symmetry and cleft-side and non-cleft-side nostril dimensions, and a significant improvement in the nasal tip protrusion-to-alar base width ratio in intermediate cleft tip rhinoplasty-treated versus control patients (p = 0.002). Conclusion The component restoration technique for the unilateral intermediate cleft tip rhinoplasty improves nasal relationships toward normal immediately and in a sustained manner for at least 3 years. Clinical question/level of evidence Therapeutic, III.

OBJECTIVE The achievement of consistently superior results in rhinoplasty is difficult. This study aimed to evaluate the effect of anchoring the columellar strut graft to the thread of the lateral crural steal for nasal tip projection and rotation. STUDY DESIGN A retrospective, case-control study. METHODS Two groups were created which consisted of patients who had a history of low nasal tip deformity according to the type of nasal tip surgery in rhinoplasty. In group 1, the lateral crural steal technique with the strut graft was used, whereas in group 2, a new technique, in which the strut graft was anchored to the thread of the lateral crural steal, was used. Patients with low nasal tip deformity due to intrinsic factors such as long lateral crura were included. The effects of the 2 different surgical approaches on facial parameters (the nasolabial angle, nasofacial angle, and Goode ratio) were statistically compared using the Mann-Whitney U test and Student t test, as applicable. RESULTS Sixty patients were enrolled: half of them were included in group 1 and the other half in group 2. Average postoperative increases of the nasolabial angle score were 10.9 ± 4.72° and 18.76 ± 6.30° in groups 1 and 2, respectively (P

The nasal tip is a complex zone for reconstruction. Numerous flap reconstructions have been proposed. In addition to the technique presented here, only the Gillies-Millard bishop’s miter flap and the paramedian forehead flap should be considered. The bilobed flap should be discontinued. The double-opposing V-Y flap for nasal tip reconstruction described here is an excellent method for reconstruction of limited defects of the nasal tip. These are mirror-image cutaneous flaps which require careful, skillful technique to preserve the delicate nerves and vessels. This challenging technique should only be attempted by qualified surgeons. Triangular cutaneous flaps are marked on either side of the defect, oriented transversely. The flaps are elevated and advanced with careful, gentle dissection. Ligamentous structures are cut while preserving the neurovascular supply. No cautery is used. The procedure is performed in an operating room with local anesthesia and with the patient under IV sedation. A patient who underwent this reconstruction is shown preoperatively, early postoperatively, and late postoperatively. The results demonstrate no tip distortion with imperceptible scars. The steps to undertake this procedure are outlined in detail. Rules for nasal tip reconstruction are proposed.

Background The septal extension graft is currently the most commonly used primary and secondary rhinoplasty technique in Asia because it provides maximal tip projection and rotational controllability. The authors compared the tip projection amount and rotational controllability of the tip support between the septal extension graft based on the L-strut septum and double-layer conchal cartilage graft based on the full septum at the nasal tip. Methods Twenty-seven consecutive patients who underwent nasal tip plasty with the septal extension graft or double-layer conchal cartilage graft for purely aesthetic reasons between March of 2014 and July of 2016 were included. The nasal tip projection and columellar labial angle preoperatively (time 0), immediately postoperatively (time 1, an average of 2 weeks after the operation), and postoperatively (time 2, an average of 7 months after the operation) were analyzed with clinical photography. Results Fourteen patients (group A) underwent septal extension graft surgery and 13 (group B) underwent double-layer conchal cartilage graft surgery. Changes of 61 and 74 percent in tip projection ratio were immediately achieved and were maintained after surgery for groups A and B, respectively (time 2 versus time 0 dividing time 1 versus time 0; p = 0.722 for groups A and B). Therefore, the relapse ratio of this technique was 39 and 26 percent for groups A and B, respectively. Conclusions This comparative study between the septal extension graft and double-layer conchal cartilage graft showed that both nasal tip plasties are similar in terms of stability. Considering the fact that the double-layer conchal cartilage graft could preserve septal support, this technique could become an effective and safe alternative option for rhinoplasty. Clinical question/level of evidence Therapeutic, III.

Care provided to the Asian rhinoplasty patient may be multidisciplinary at times, including not only plastic surgeons, but also other health care professionals. It is crucial that all physicians caring for these patients practice complete awareness of the patient's prior operations and details of materials used in order to optimize results and avoid potentially devastating complications. These complications include but are not limited to implant infection and extrusion. Here the authors describe one such case report, discussing dermatologic biopsy of a silicone implant of the nasal tip and dorsum and subsequent revision rhinoplasty with implant removal and costochondral graft placement.

INTRODUCTION This study compared the subjective measurement of difference between the nasal tip and supra tip (TSD) (using eyes) versus objective measurement of TSD (by a ruler) during rhinoplastic surgery to determine the accuracy of subjective measurements among surgeons with varying degrees of experience. MATERIALS AND METHODS In this analytical observational study, 40 cosmetic rhinoplasty candidates were involved. Those with the history of rhinoplastic surgery were excluded from the study. At the end of the operation, the surgeon was asked to estimate the TSD subjectively. The researcher, without the intervention of the surgeon, remeasured TSD by a presterile ruler. The researcher recorded both objective and subjective TSD measurements and the experience of the surgeon in rhinoplasty in the checklist. RESULT Of 40 cosmetic rhinoplasty candidates, 17 were operated by a surgeon with >10 years' experience (group 1), and 23 by a surgeon with

Nasal tip refinement is one of the most difficult aspects of rhinoplasty surgery. In this article, the senior author (R.J.R.) presents his technique for nasal tip analysis and identifies the factors that contribute to nasal tip shape. Various techniques for nasal tip modification using both sutures and soft cartilage grafts are described to help produce optimal results.

Objectives The objectives of this study were to evaluate sexual dimorphism for facial features within Colombian and Mexican-American populations and to compare the facial morphology by sex between these 2 populations. Materials and methods Three-dimensional facial images were acquired by using the portable 3dMDface system, which captured 223 subjects from 2 population groups of Colombians (n = 131) and Mexican-Americans (n = 92). Each population was categorized into male and female groups for evaluation. All subjects in the groups were aged between 18 and 30 years and had no apparent facial anomalies. A total of 21 anthropometric landmarks were identified on the 3-dimensional faces of each subject. The independent t test was used to analyze each data set obtained within each subgroup. Results The Colombian males showed significantly greater width of the outercanthal width, eye fissure length, and orbitale than the Colombian females. The Colombian females had significantly smaller lip and mouth measurements for all distances except upper vermillion height than Colombian males. The Mexican-American females had significantly smaller measurements with regard to the nose than Mexican-American males. Meanwhile, the heights of the face, the upper face, the lower face, and the mandible were all significantly less in the Mexican-American females. The intercanthal and outercanthal widths were significantly greater in the Mexican-American males and females. Meanwhile, the orbitale distance of Mexican-American sexes was significantly smaller than those of the Colombian males and females. The Mexican-American group had significantly larger nose width and length of alare than the Colombian group regarding both sexes. With respect to the nasal tip protrusion and nose height, they were significantly smaller in the Colombian females than in the Mexican-American females. The face width was significantly greater in the Colombian males and females. Conclusions Sexual dimorphism for facial features was presented in both the Colombian and Mexican-American populations. In addition, there were significant differences in facial morphology between these 2 populations.

Functional and aesthetic manipulation of the nose relies on a detailed understanding of nasal anatomy and a meticulous dissection. Maneuvers are performed in four regions of the nose: nasal tip, dorsum, posterior septum, and caudal septum. Positioned at the cornerstone of these regions, the anterior septal angle acts as a point of reference, especially in secondary rhinoplasty. Identification of the anterior septal angle early in the nasal dissection aids in reliable exposure, either wide or limited, and facilitates desired maneuvers. In addition, alteration of the position of the anterior septal angle can affect nasal tip projection, especially in cases such as the tension tip deformity. The authors emphasize the importance of the anterior septal angle in their simplified methodology for the open dorsal approach in rhinoplasty.

Background Single-stage reconstruction of the nasal tip using frontonasal flaps yields variable results. Variations in flap design were used to optimize outcome. Methods Consecutive nasal tip reconstructions using frontonasal flaps performed by the author during a 6-year period were studied retrospectively. Patients were followed up clinically and charts were reviewed for defect size, vertical orientation (tip versus supratip), and horizontal orientation (central versus lateral). Surgical reports and digital photographs were evaluated for flap design that was adapted to the defect, individual anatomy, and the nasal subunit concept. Flaps were classified by size (standard versus extended), proximal scar configuration (angular versus curved), and distal scar configuration (straight versus stairstep). Surgical complications and aesthetic outcomes were evaluated. Results Twenty-nine frontonasal flaps were performed in 16 female and 13 male patients with a mean age of 73 years. The average defect diameter was 2 cm. The average surface area was 4 cm. Primary defects were located at the tip in 22 cases and the supratip in seven cases, with 19 being lateral and 10 being central. Standard flaps were chosen in 13 patients and extended flaps in 16 patients. Proximal scar configuration was angular in 20 cases and curved in nine cases. Distals scar configuration was straight in 21 patients and stairstep in eight cases. Minor flap complications occurred in eight patients. Outcome was rated good to excellent in 97 percent of patients. Conclusion Aesthetically pleasing single-stage reconstruction of the nasal tip is attainable using an anatomically based approach to frontonasal flap design. Clinical question/level of evidence Therapeutic, IV.

The present study was undertaken to determine whether a more aesthetically acceptable nostril shape could be created by manipulating the dilator naris muscles. Patients who had round or horizontally shaped nostrils were treated by resecting the dilator naris muscle to attenuate the dilating and lateral pulling effect of the muscles. The resected muscle segments were inserted into the nasal tip area to project the nasal tip. Manipulating the dilator muscle shaped the nostril more vertically and enhanced nasal tip augmentation. The ratio of the short axis to the long axis of the nostril was improved significantly. The interaxial angle became more acute. The patient satisfaction score was also increased. A more aesthetically pleasing nostril shape can be produced by resecting and grafting the dilator naris muscle segments. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

The aim of this study was to describe a novel surgical suture technique for achieving ideal nasal tip rotation and projection with nasal supratip angle. The figure-of-eight suspension suture (FOESS) technique was used in 68 patients who underwent open technique septorhinoplasty operation between the years 2013 and 2015. Fifty-four of the patients were female and 14 were male. The mean age of the patients was 28.2. The mean follow-up time of the patients was between 6 and 18 months. No complications were observed due to the FOESS technique. Satisfactory results were obtained in the postoperative period after surgery. The FOESS technique generated power against the anterior-inferior tensile strength of the alar cartilages. Thus, it can be possible to shape the nasal tip rotation and projection in the desired dimensions. In addition, this technique helps us to create supratip break point and angle.

Summary:. The cosmetic appeal of the nose is very important, as it is a structure located at the center of the face. Hence, the removal of nasal tumors requires matching aesthetic subunits for the ensuing reconstruction. This procedure often creates large defects that require skin grafts or local flaps for repair. If a large skin graft is required, harvesting of flaps from the head and neck region might have some limitations. Although flaps from the forehead can cover a wide range of facial defects, the skin properties of the forehead differ from those of the rest of the face. Moreover, early postoperative flap deformation may be due to the flap volume and the need for multiple surgeries, leading to vertical forehead scarring. Particularly, vertical forehead scars are more noticeable in Asians than in Westerners. Previously, grafts have been harvested from a unilateral nasolabial fold, but these grafts were small and resulted in asymmetry. Herein, we describe the case of a 67-year-old man with a basal cell carcinoma of the nasal tip, in which closure of the large defect was achieved through excision matching of the aesthetic unit by using skin harvested from bilateral nasolabial folds.

Summary Carcinoma cuniculatum, also known as cutaneous verrucous carcinoma, is a rare, low-grade, well-differentiated squamous cell carcinoma usually involving the foot. It is often locally aggressive but rarely metastatic. Only 10 cases involving the skin of the face (except the lips and scalp) have been reported. We describe a 74-year-old man who presented with carcinoma cuniculatum on the nasal tip arising from a keratoacanthoma-like lesion. To our knowledge, this is the first report of such a case in the literature. Literature related to carcinoma cuniculatum is also reviewed, and the challenges in diagnosis and choice of treatment are also described. In this case, the patient initially presented with keratoacanthoma on the nasal tip, and rapid recurrence with a verrucous mass occurred 1 month following tumor excision. Wide excision with 5-mm safe margins and full-thickness skin graft resurfacing were performed smoothly after recurrence. Histopathologic examination revealed carcinoma cuniculatum. The patient recovered uneventfully, and no recurrence of the lesion was reported over a 62-month period of observation. Overall, the prognosis of carcinoma cuniculatum is usually favorable. However, early diagnosis and treatment of carcinoma cuniculatum are crucial by clinicopathological standards. General clinical awareness of this entity contributed to more appropriate and timely treatment.

There is still no reliable tool to determine the outcome of the repaired unilateral cleft lip (UCL). The aim of this study was therefore to develop an accurate, reliable tool to measure vertical lip height from photographs. The authors measured the vertical height of the cutaneous and vermilion parts of the lip in 72 anterior-posterior view photographs of 17 patients with repairs to a UCL. Points on the lip's white roll and vermillion were marked on both the cleft and the noncleft sides on each image. Two new concepts were tested. First, photographs were standardized using the horizontal (medial to lateral) eye fissure width (EFW) for calibration. Second, the authors tested the interpupillary line (IPL) and the alar base line (ABL) for their reliability as horizontal lines of reference. Measurements were taken by 2 independent researchers, at 2 different time points each. Overall 2304 data points were obtained and analyzed. Results showed that the method was very effective in measuring the height of the lip on the cleft side with the noncleft side. When using the IPL, inter- and intra-rater reliability was 0.99 to 1.0, with the ABL it varied from 0.91 to 0.99 with one exception at 0.84. The IPL was easier to define because in some subjects the overhanging nasal tip obscured the alar base and gave more consistent measurements possibly because the reconstructed alar base was sometimes indistinct. However, measurements from the IPL can only give the percentage difference between the left and right sides of the lip, whereas those from the ABL can also give exact measurements. Patient examples were given that show how the measurements correlate with clinical assessment. The authors propose this method of photogrammetry with the innovative use of the IPL as a reliable horizontal plane and use of the EFW for calibration as a useful and reliable tool to assess the outcome of UCL repair.

Augmentation rhinoplasty is one of the most popular cosmetic surgeries in Asia, and both dorsal augmentation and mobile nose modifications are emphasized for the characters of the Asian nose and for Asians who are fond of the Western nasal shape. The goal in rhinoplasty is to create a balanced and natural appearance. Therefore, the cosmetic aspects, postoperative complications, and functional aspects should be regarded as a whole. In fact, the first 2 aspects had been widely reported in a large number of literatures. However, the functional aspects about mobility have been ignored by most surgeons. A sample method was used in this article to investigate the range of mobility of normal nasal tip in Asians and analyze the correlations of the nasal mobility and alloplastic materials. A total of 170 healthy adult subjects aged from 18 to 35 were included and were classified into 3 groups standing for normal nose and rhinoplasty with L-shaped silicon implants with e-PTFE implants. A 3D raster surface scanner was used to capture the images of the subjects accurately and rapidly in this detailed anatomical study. The range of nasal mobility (to right or left) in Asian normal women was 35.53 ± 4.84 degrees, and the length of mobile part was 16.62 ± 1.94 mm, which accounts for 40% ± 5% of nasal length. The L-shaped alloplastic implants would reduce the nasal mobility, and there had been differences among the changes caused by different implants, which might cause unsatisfactory outcomes in patients. Results of the study indicated that augmentation rhinoplasty should be performed as well as augmented mammaplasty which attaches importance not only to the static and dynamic appearance of the nasal tip but also to the feeling when it is touched.

Background One of the main operative goals achieved with tip surgery is to reach the ideal nasolabial angle. The main purpose of the current study was to compare the effects of alar cartilage vertical incision and shortening (ACS) and columellar-septal suture (CSS) techniques on the nasolabial angle. Methods In this retrospective study, 2 groups were examined: the patients in the first group were operated on using vertical alar cartilage incision and shortening, and the patients in the second group were operated on using columellar-septal cartilage suture. Postoperative photographs between the 2 groups were compared with respect to nasolabial angle differences. Statistical analysis was done with SPSS version 20. Results In the postoperative evaluation, 50% of ACS and 72.5% of CSS groups had achieved desired clinical outcomes. Although the efficacy of the CSS group was found to be superior to that of the ACS group, there was no statistically significant difference between the groups. Greater nasolabial angle was gained using the CSS technique; however, the risk for overrotation was higher in the CSS group. Conclusions Both ACS and CSS techniques provide reliable reconstructive option for nasolabial angle modifications. More predictable results were obtained with the ACS technique. The CSS technique is a versatile way of nasolabial angle alteration, but there is a higher risk for overrotation.

Background The effect of a columellar strut graft on final nasal tip position has been a subject of ongoing debate. The purpose of this study was to retrospectively analyze a series of 100 consecutive primary rhinoplasty cases performed without the use of columellar strut grafts, with a specific focus directed toward comparing preoperative, morphed, and actual postoperative changes in nasal tip position. Methods Data were collected from patient charts and digital images of 100 consecutive primary open rhinoplasty patients. Preoperative, morphed, and actual postoperative digital images were quantitatively analyzed using image-processing software to compare various anatomical features, including nasal tip projection, nasolabial angle, and Goode ratio. Patient satisfaction regarding long-term postoperative results was also surveyed. Results Primary rhinoplasty did not demonstrate a universal trend toward either an increase or a decrease in nasal tip projection. The planned changes in nasal tip projection, nasal tip rotation, and nasal profile proportions were obtained with statistically significant accuracy without the use of columellar strut grafts. The overall incidence of columellar contour irregularities was 3 percent. Conclusion In primary open approach rhinoplasty, if native anatomical support structures of the nasal tip are preserved or reconstructed, preoperative goals regarding nasal tip projection, nasal profile proportions, and columellar integrity can be consistently achieved without using columellar strut grafts.

Background Secondary cleft nasal deformity is a combination of the inherent cleft defects and the effects of operations to address the primary nasal deformity. The authors revisited a modified V-Y chondromucosal flap to restore symmetric nostril shape and balanced tip projection. Methods A retrospective case-control study of the senior author's (J.A.T.) experience with secondary cleft tip rhinoplasty using the V-Y chondromucosal flap was conducted. Preoperative and postoperative anteroposterior and worm's-eye photographs were compared by means of photogrammetric analysis. Results were compared with those of controls who had not undergone surgery. Interrater reliability was assessed using the Pearson coefficient. Results Seventeen cases and 24 controls were reviewed. Average age at repair was 9.3±3.6 years; average follow-up was 13 months. Interrater reliability was 0.98 overall. Photogrammetric analysis demonstrated postoperative increases in cleft-side columella length by 2.3 mm (p=0.0001) and nasal apex height by 1.3 mm (p=0.003); non-cleft-side measurements were statistically unchanged. Control measurements were similar across 1-year visit interval, and when compared with cases, patients undergoing tip rhinoplasty had significantly different cleft-side columella length postoperatively (increase of 2.31 mm versus 0.15 mm; p=0.0002) and nasal apex height (increase of 1.29 mm versus 0.17 mm; p=0.03). All other parameters remained comparable. No complications and no external nasal valve collapse were observed. Conclusions In select patients, use of a V-Y chondromucosal flap increased cleft-side nasal tip projection and columellar height, improving overall nasal tip appearance. Although absolute width of the cleft alar base is unchanged, the cleft-side nostril is qualitatively more symmetric postoperatively. Clinical question/level of evidence Therapeutic, III.

Objective The aim of the study was to evaluate postoperative changes of the nasal tip in patients who underwent internal nasal valve reconstruction with the auricular cartilage butterfly graft. It is believed that this graft may alter the nasal tip appearance, potentially limiting the technique's broad use despite its proven efficacy. Methods or design A retrospective chart and photograph review, between 2005 and 2009, identified 157 patients who underwent butterfly grafting without other tip modifications at a single institution by 1 surgeon. Changes in supratip projection were measured in the lateral view, and changes in tip width were measured in the frontal view from preoperative to 3-month postoperative photographs. Results For 21 subjects (12 female and 9 male), the change in tip width ranged from -10.2% to +15.7% (absolute mean 6.4%), and the change in supratip projection ranged from -23.4% to +15.0% (absolute mean 8.5%). Nine subjects with increased projection showed a mean increase of 7.0%, and a mean decrease of 9.7% was found in the 12 subjects with decreased supratip projection. Conclusions The butterfly graft for internal nasal valve dysfunction results in cosmetic alteration to nasal tip width with a mean change of 6.4%. The change in supratip projection showed greater variability possibly related to purposeful cosmetic changes. Depending on the patient's level of nasal dysfunction, the 6.4% mean change in nasal tip width may be more or less personally significant.

Supplemental Digital Content is available in the text., Background: Strong strut structures are necessary for nasal tip projection in Asian rhinoplasty. Traditionally, strut structures have been constructed by open skin incisions. Methods: Barbed threads were implanted for rhinoplasties. The threads have multiple sharp barbs and umbrella-like longitudinal splits at both ends. Autologous micronized fat tissue graft was also simultaneously used when volume replacement was necessary. Results: Since 2003, barbed threads have been used in approximately 1,200 rhinoplasties for nasal tip projection, dorsal length elongation, and nostril correction. The results of relative length ratios comparing true lateral photographs showed significant increase in tip projection. Conclusion: The results of long-term observation (> 6 months) indicate that the surgical procedure of lifting the nasal tips with barbed threads is significantly effective for the anterior projection of nasal tip in Asians.

Cutaneous metastatic tumors to the nasal tip are very rare. A 74-year-old woman presented with progressive dysphagia for 4 months and a painless red violaceous nodule in the nasal tip for the last 6 weeks. Gastroendoscopy showed midesophageal wall thickening, which corresponded to esophageal squamous cell carcinoma confirmed by endoscopic biopsy. 18F-FDG PET/CT showed intense FDG uptake of the esophageal carcinoma (SUVmax, 19.0) and the nasal tip nodule (SUVmax, 29.1). The patient underwent biopsy of the nasal tip nodule. Nasal tip metastasis from the esophageal squamous cell carcinoma was confirmed by pathologic examination.

Frontoorbital advancement (FOA) improves forehead and superior orbital asymmetry associated with unilateral coronal synostosis but has little effect on facial asymmetry. This study compares frontofacial symmetry after FOA and endoscopically assisted suturectomy (ESC) and postoperative helmet therapy.A retrospective review of 2 cohorts of patients with nonsyndromic unilateral coronal synostosis who had either FOA or ESC was undertaken. Choice of procedure was determined by age of patient at referral (younger than 4 months, FOA or ESC; older than 4 months, only FOA). Vectra 3D imaging system (Canfield Imaging Systems, Fairfield, NJ) was used to capture and analyze three-dimensional digital images. Comparative anthropometric measurements were made and statistically analyzed.Twenty-two patients met the inclusion criteria; 11 underwent ESC at mean age of 2 months (range, 1-4 months) and 11 underwent FOA at mean age of 12 months (range, 8-25 months). Mean age at three-dimensional digital imaging was 45.9 months (range, 18-64 months) for the FOA group and 34.5 months (range, 20-66 months) for the ESC group (P = 0.054).There was no difference between the 2 groups with regard to supraorbital symmetry (P = 0.54). The ESC group exhibited better facial symmetry in midline deviation (3.6° vs 1.4°; P = 0.018), nasal tip deviation (5.6° vs 2.3°; P = 0.006), and middle facial depth (6.9 vs 4.4 mm; P = 0.042). Lower facial depth was similar (3.8 vs 2.3 mm; P = 0.54).Early ESC and helmet therapy results in comparable brow symmetry and better overall facial symmetry than FOA done in late infancy.