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Treatment of nasal base deformities is critical for a successful rhinoplasty. Several anatomic variations are seen on nasal base. Alar base deformities can be horizontal excess or deficiency, vertical excess or deficiency, cephalic malposition or caudal malposition of alar base, wide or narrow nostril sills, and columellar base deformities. Columellar base should be addressed before alar base resections. Correction of columellar base deformities and positioning of medial crural footplates should be the primary step of nasal base surgery to attain aesthetic ideals of the columellar base and improve external nasal valve function. The most common deformities requiring alar base modification include wide nasal base, alar flaring, large nostril size, and asymmetries of nostrils or alae. There are 3 basic types of excision on alar base surgery. (1) Alar wedge excision, (2) nostril sill excision, and (3) combined alar wedge and nostril sill excision. The alar wedge excision is an elliptical excision placed in the alar crease that is used to reduce the size and shorten the vertical length of alar lobule and correct the excessive flaring on the frontal view. Nostril sill excision is the technique which is used to decrease interalar distance and nostril sill length, and reduce the size of nostril. The combined alar wedge and nostril sill excision is used in cases with wide alar base and additionally, there is excessive flaring and large alar lobule.

Introduction:We aimed at comparing nasal tip projection and nasolabial angle changes following primary open rhinoplasty with short-floating columellar strut graft and suture techniques.Methods:Participants were divided into two groups depending on the type of technique employed. In the first group, short-floating columellar strut grafts were employed. The second group involved those who underwent suture techniques only.Results:We included 119 patients who underwent primary rhinoplasty in the study. The mean value of preoperative nasolabial angle measurement was 92.77±8.5 degrees and 92.14±6.7 degrees in groups 1 and 2, respectively. Postoperative nasolabial angle measurement in group 1 was 107.2, 104.3 and 101.3 degrees in the 1st, 3rd, and 5th postoperative year, respectively. Postoperative nasolabial angle measurement in group 2 was 107.4, 104, and 102.2 degrees in the 1st, 3rd, and 5th postoperative year respectively. The mean value of preoperative nasal tip projection was 0.605±0.07 and 0.653±0.08 in groups 1 and 2, respectively. Postoperative nasal tip projection measurement in group 1 was 0.636, 0.632 and 0.627 in the 1st, 3rd, and 5th postoperative year, respectively. Postoperative nasal tip projection measurement in group 2 was 0.656, 0.634 and 0.632 in the 1st, 3rd, and 5th postoperative year, respectively.Conclusion:Suture techniques were efficient than columellar strut grafts in maintaining the nasolabial angle but not the nasal tip projection when.

Symmetric pocket formation and meticulous implant carving are the most critical parts of nasal dorsal augmentation using implants. Innovative three-dimensional printed nasal implants can exactly fit the nasal dorsal contour, decreasing the chance of deviation and malpositioning. Vertically oriented folded dermal graft technique can avoid the high resorption rate of conventional dermofat grafts. Multilayered costal cartilage graft technique for dorsal augmentation can minimize warping and difficulty in the graft carving. Derotation graft allows supple and movable nasal tip while enabling enough tip lengthening, even if the septal extension graft is the most commonly performed procedure for short nose correction.

The main objectives of rhinoplasty in African descendants are to improve the definition and projection of the nasal tip, augment the dorsum, and reduce the alar base. Open rhinoplasty using costal cartilage graft, with lateral crural tensioning and septal extension graft associated with en bloc dorsal augmentation is the workhorse. Cartilage resections should be minimal. Oral isotretinoin and triamcinolone injection may improve tip definition. Surgical success ultimately depends on the ability of the surgeon to accurately identify the anatomic variables and reconcile these anatomic realities with the patient's aesthetic expectations and his or her sense of ethnic identity.

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.

Background Three-dimensional surface imaging is established in many disciplines for objective facial acquisition regarding anthropometry. Former studies addressed the validation of landmark-based measurements for single race. In order to distinguish racial difference, the reproducibility of the landmark measurements must first be validated. Objectives Our purpose is to validate the reproducibility of 46 facial soft-tissue landmarks on x, y, z axes to prove their reliability as 3D reference points. Methods The study included 80 European Caucasian and 80 Chinese volunteers. Standardized 3D surface imaging was performed using Vectra 3D system. Two raters identified and defined 46 landmarks (138 coordinates), then repeatedly 3D-imaged volunteers' facial region in separate sessions. Coordinates' reproducibility of landmarks is divided into three categories (< 0.5 mm, < 1 mm, and >1 mm) for intra- and inter-rater reproducibility assessments. Results Coordinates' reproducibility of 160 samples was distributed as follows: Intra-rater: < 0.5 mm (45%), < 1 mm (42%), >1 mm (13%); inter-rater: < 0.5 mm (31.2%), < 1 mm (42%), > 1 mm (26.8%). The reproducibility of landmarks in nasal tip region differs slightly between Caucasians and Asians. Compared to females, males typically have higher landmark reproducibility in lip and chin region. However, there were no differences in the reproducibility ranking of landmarks by gender. Conclusion The majority of the 46 landmarks in the 3D plane are reproducible to 1 mm, which is clinically acceptable. All selected landmarks showed strong consistency across race and gender, suggesting their potential use as reference points in prospective clinical practice. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

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.

Background: The aim of this study was to examine the influence of sagittal dentoskeletal pattern on the value of profile nasal soft tissue angles and estimate the significance of examined differences for each angle. Materials and methods: Lateral cephalograms were used to examine the nasofrontal angle, nasofacial angle, nasal tip angle, and nasolabial angle of 120 adult Caucasian subjects (60 male and 60 female) from the central Balkan area. Subjects were divided into four groups according to the ANB angle and incisors inclination: class I as the control group, class II division 1, class II division 2 and class III. Results: By evaluating the influence of sagittal dentoskeletal relationships on the values of examined angles, significant differences were found among subjects with class I and class II/2 (p = 0.028), so as class III (p = 0.002) for nasal tip angle. The nasofacial angle was found to differ among subjects with class I and class II/1 (p = 0.002), so as class III (p = 0.001). Conclusions: Different dentoskeletal patterns have significant influence on values of the nasal tip angle and nasofacial angle, and don’t have influence on the values of the nasofrontal and nasolabial angle.

Aleksandra Bolewska,1 Monika S&lstrok;owi&nacute;ska,1 Agata B&lstrok;o&nacute;ska,1 Justyna Ceryn,2 Bart&lstrok;omiej Grala,3 Joanna Narbutt,2 Magdalena Ci&aogon;&zdot;y&nacute;ska,4 Wojciech Ma&lstrok;ecki,5 Ma&lstrok;gorzata Skibi&nacute;ska,2 Aleksandra Lesiak,2 Elwira Paluchowska,1 Witold Owczarek1 1Department of Dermatology, Military Institute of Medicine, Warsaw, Poland; 2Department of Dermatology, Pediatric Dermatology and Oncology, Medical University of Lodz, &Lstrok;ód&zacute;, Poland; 3Department of Pathology, Military Institute of Medicine, Warsaw, Poland; 4Department of Proliferative Diseases, Nicolaus Copernicus Multidisciplinary Centre for Oncology and Traumatology, &Lstrok;ód&zacute;, Poland; 5Department of Clinical Oncology and Chemotherapy, Podd&eogon;bice Health Centre, Podd&eogon;bice, PolandCorrespondence: Aleksandra Bolewska Tel +48 261 816 241; +48 604 783 340Email aleksandra.bolewska@wp.plAbstract: Lung cancer most often metastasizes to the central nervous system, bone and liver. Although metastases to the skin are quite rare, it is estimated that they may be the first clinical manifestation of this disease in 0.7%– 12% of cases. Metastases to the skin are caused by adenocarcinoma (about 30%), squamous cell carcinoma (30%) and undifferentiated carcinoma (40%). Nasal tip metastases are extremely rare. They can be confused with more common skin problems, including non-melanoma skin cancers, rhinophyma, inflammatory tumors or infectious diseases. We report two patients with a tumor on the nose, which proved to be the first sign of the metastatic lung cancer.Keywords: lung cancer, skin metastasis, ulceration, tumor

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.

Despite the great demand of aesthetic rhinoplasty in Asian population, it is difficult to obtain the lasting ideal tip projection along with lengthening of the nose due to the small and weak nasal septum. The shortage of available septal cartilage to work with is another major obstacle. A retrospective study was conducted between January 2017 and December 2019 in Seoul, Korea. A total of 774 patients underwent septorhinoplasty using polycaprolactone (PCL) mesh for the cosmetic enhancement of the nasal tip and the projection. Comparisons of aesthetic outcomes, patients' satisfaction surveys, and complications were performed between PCL mesh-only group and composite PCL group. Of all the patients, 97.5% of the patients in composite PCL group were rated more than 3 scores in aesthetic outcomes, whereas 90.4% in mesh-only group (p-value = 0.0002). About 96.7% of the patients with composite PCL rated their satisfaction level as more than satisfied, whereas 94.3% in mesh-only group (p-value = 0.0365). Overall, there were 17 patients in composite PCL group who exhibited complications including decreased tip projection, deviated nasal tip, mesh infection, and mesh exposure. However, there were two patients who had mesh injection in mesh-only group. Septorhinoplasty with septal extension graft using composite PCL graft provides robust support to the aesthetically modified projection and the lengthened nose without obvious complications on the nasal tip. Such technique allows surgeons to overcome the nature of Asian nose that is weak and small, and also provides satisfaction to patients who desire ideal tip projections and dramatic changes.

The outcome of rhinoplasty was evaluated in patients undergoing tongue-in-groove technique (TIG) with and without septal extension grafts (SEG) placement for stabilization of nasal tip rotation. Three hundred and sixty-seven patients who underwent rhinoplasty using TIG from 2016 to 2020 were included in this study. SEG was used if the caudal segment of the septum was not suitable for TIG. All patients were photographed pre- and postoperatively. Columellar Facial angle (CFA) and Nasolabial angle (NLA) were measured preoperatively at three intervals including up to six months after the operation (early or T1), up to one year after T1 (midterm or T2), and up to two years after T2 (late or T3). Two hundred and nine patients (56.94%) underwent TIG and the rest of them (43.06%) received SEG plus TIG (SEG+TIG). The TIG group had a mean CFA of 95.9±7.56 degrees preoperatively, 106.5±6.77 degrees at T1, 105.4±6.48 degrees at T2, and 104.8 ±7.52 at T3. The SEG+TIG had a mean CFA of 98.9±7.65 degrees preoperatively, 108.8±6.58 degrees at T1, 107.7±6.86 degrees at T2, and 106.2 ±15.6 at T3. Comparison of T1, T2, and T3 showed that the CFA changes were less than 1%, indicating a nonsignificant difference. The same results were obtained for NLA as well. Adding of SEG to TIG may be an effective technique to create and maintain a stable rotation comparing to TIG independently. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The T-graft is a new tool in the armament of structural rhinoplasty. The graft makes it easy to create a well- balanced nasal framework both for beginners and more experienced rhinoplastic surgeons. Due to its multifunctional character the T-graft allows the surgeon to control nasal length as well as nasal tip projection and -rotation. The T-graft is indicated in many anatomical features like in patients with a short nose or heavy soft tissue envelope, but also in patients with under projection of the nasal tip, under- or over-rotation of the nasal tip and deviations of the caudal nasal septum.

Numerous flap design techniques have been proposed for soft tissue reconstruction of the nasal tip. The modified horn flap based on the superior alar artery and nasalis muscle is the preferred option for defects ranging in size from 1 to 2 cm vertically and 1.5 to 3 cm horizontally after skin cancer excision. This innovative technique is a reliable and versatile island flap for reconstruction of the nasal tip in a one-stage operation, providing successful functional and aesthetic results, as tissues for the flap are generated from the nose. The contribution of the superior alar artery, which forms the vascular axis of the flap, plays a vital role in flap survival – together with part of the nasalis muscle.

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.

By performing a preservation rhinoplasty, the surgeon can achieve natural and stable results by intraoperative replacement of resection with preservation and excision with manipulation of ligaments, cartilages, soft tissues, and the osseocartilaginous dorsum. In this article, the authors explain step by step the dorsal preservation rhinoplasty with low septal strip and a combination of nasal bones osteoplasty and osteotomies, the tip preservation rhinoplasty based on nose tip polygons, and the authors' technique for modify the nasal tip projection and rotation with a posterior strut or anterior septal strip.

Nasal tip deformities after primary rhinoplasty may occur, including the formation of bossae, a pinched nasal tip, and nasal tip ischemia. Because of the central location in the midface, even minimal nasal tip deformities (small bossa) may be noticed and upsetting to the patient. This is in addition to more severe nasal tip deformities, including nasal tip ischemia, that are easily visible to any viewer. Prevention, early recognition, and, depending on the case, intervention are critical in minimizing these complications. If complications do occur, regular communication with the patient and follow-up are crucial.

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.

A 28-year-old female patient presented at ENT OPD with complaints of a slowly growing mass over nasal tip since last 5 years. There were no complaints of pain, nasal obstruction, or epistaxis. There were no skin changes or ulceration over the swelling and sensation was preserved. There was no history of similar kind of swelling in other parts of the body. History of trauma or any form of surgical intervention were excluded. Family history was insignificant. The swelling did not respond to any medications. The patient attended for cosmetic reason solely. Clinical examination showed a soft non-tender 4 cm by 4 cm mass over nasal tip and supratip area. Mobility of the mass was restricted and fixed to the alar cartilages. There was no evidence of café au lait spots or any other skin lesions. Anterior rhinoscopy was unremarkable. Diagnostic nasal endoscopy was also performed but no abnormality was detected. CT scan showed non-specific infiltrative subcutaneous lesions. T1W MRI showed an ill-defined hypodense mass over the nasal tip which was abutting the alar cartilages which showed mild enhancement with contrast (figure 1). T2W MRI showed hyperintense and or hypodense central focus (target sign). FNAC was done and report was suggestive of neurogenic tumour, most probably neurofibroma.

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.

Background Cephalic malposition of the lower lateral cartilages is a common nasal anatomic variation. Knowing the range of lateral crura (LC) divergence angle in Iranian population can help Middle East plastic surgeons. This study aimed to determine LC divergence angle of candidates for primary rhinoplasty in Iranian population. Methods This cross-sectional study was conducted on 256 candidates for primary rhinoplasty from November 2017 through May 2018. Two sides of LC divergence angle were measured intraoperatively by a researcher-made device. Results Totally, 211 female and 45 male patients with the mean age of 29.9±6.51 years were recruited. The mean LC divergence angle was 35.86±4.74° (between 20-50°). The mean LC divergence angle was 35.11° and 36.02° in male and females, respectively. There was no significant difference between males and females. In addition, there was no significant correlation between LC divergence angle and age. LC divergence angle had normal distribution and about 68% of the LC divergence angle were within one standard deviation of the mean (i.e. 32 to 40 degree). Conclusion In 16% of studied people, the divergence angle of the lateral crus of the lower lateral cartilage was lower than 32° and was considered as malposition.

Reconstruction of the tip of the nose following the excision of skin cancer is a cosmetic and surgical challenge. We propose using a crescentic nasojugal flap, also known as a perialar crescentic advancement flap, to repair such defects. We present a series of 13 cases in which cutaneous carcinoma (mostly basal cell carcinoma) was excised from the lateral nasal tip with clear margins and the defect repaired with a crescentic nasojugal flap. The technique was successful in all cases. None of the patients developed notable surgical complications and the postoperative outcomes were satisfactory, with no significant functional or cosmetic problems. The crescentic nasojugal flap is therefore a good option for repairing medium-sized defects on the tip of the nose.

To compare three-dimensional (3D) nasal forms after definitive correction of unilateral cleft lip (UCL)-nose using an extended spreader cartilage graft with/without a cross-lap joint cartilage graft technique. Twenty-four patients with UCL who underwent definitive nose correction using an extended spreader cartilage graft with a cross-lap joint technique (CLJ group) and fifteen patients with UCL who underwent nose correction without a cross-lap joint technique (non-CLJ group) were enrolled in this study. Pre- and postoperative 3D nasal forms were compared between the two groups. The CLJ group demonstrated more successful recovery of the nasal tip and anterior nasal ridge in the center of the face (P 0.01), and the higher nasal tip was maintained for more than 1 year (P = 0.008). The differences in the cephalo-caudal heights of the nasal alar groove and curvatures of the alar groove arch were successfully improved in both CLJ and non-CLJ groups. The nasal angles on lateral profiles did not change in either group. An extended spreader cartilage graft with a cross-lap joint technique facilitates satisfactory recovery of the nasal tip in the center of the face and a higher nasal tip, avoiding over-projection in the definitive correction of UCL-nose.

Head and neck injury as a consequence of in utero pressure and birth trauma is a rare event. We report a case of a patient who was born full-term via vaginal delivery and presented soon after birth with skin changes over the nasal tip consistent with a pressure-related injury that progressed to a stable eschar. Conservative management with close clinical monitoring resulted in a well-healed wound over the nasal tip. A detailed discussion regarding the diagnosis and management of head and neck lesions after birth is provided.

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

For East Asians, rhinoplasty procedures are predominantly focused on reconstructing a well-defined nasal tip. In this study, the authors present a new graft design for the columellar strut that is similar to the shape of a comma mark. As one integrated piece, the graft undertakes the roles of providing solid support for the tip, modifying different angles, as well as relationships between the tip and columella. One hundred and sixty-five female patients, ranging in age from 18 to 42 years (average 27.1 years), received augmentation rhinoplasty surgery over the past 4 years with an average postoperative follow-up of 12 months. Among these patients, 78 of them were primary cases and others were secondary or more. The cartilaginous framework was reconstructed based on comma strut with other grafts including spreaders and dorsal onlay grafts. Patients’ own evaluations on the overall improvements of the nose rendered high satisfaction rate. During the long-term follow-up, 8 cases presented asymmetrical nostrils with slightly deviated columella; minor revision surgeries were performed. Another 3 cases presented dorsal graft warping and were also corrected. No other major complications were encountered. The comma strut provides a reliable support for the nasal tip; its dual curved structure plays the instrumental role in defining the lobular-columellar angle as well as modifying the supratip break. This graft design offers good control of tip and columella; as a result, consistent, reproducible results can be achieved. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Of the first nasal tip modeling procedures performed, the Anderson tripod concept is the most well known, and many anatomy-related studies have analyzed the components involved in tip surgery. The main goals of nasal tip surgery are to stabilize the tip complex, which largely affects the shape, projection and rotation of the nasal tip. The present study describes a new, original method, the double columellar strut and its main advantages compared to conventional techniques used for structural rhinoplasty. The study involved 642 patients (496 women and 146 men, with an average age of 38.67 years) who underwent surgery between 2004 and 2018 by two operators. The patients were re-examined to evaluate the outcomes at least 1 year after surgery, and long-term results (15 years) were recorded for the oldest patients in regard to esthetics (projection, shape, rotation) and breathing function. Of the 642 patients, 34 required a surgical revision for minor defects of the tip due to asymmetry, and the natural appearance after the first surgery was not affected. For the primary rhinoplasties, there were no breathing disorders that required revision surgery due to systematic restoration or preservation of the middle third. The double columellar strut could be performed in the same conditions that the others conventional structural grafts. As a polyvalent alternative, it can be used with closed or open approaches and involves the use of only a limited amount of cartilaginous material. This anatomical approach yields natural results, acting as a foundation for controlling the shape, projection and rotation of the nasal tip. In addition, with or without complementary techniques such as the “tongue-in-groove” technique or tip grafts, the double columellar strut can be considered a “multifunction pocket knife” for tip surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

It is important to reinforce nasal tip support for long-term satisfactory results. Two workhorses of tip support are strut grafting and the tongue-in-groove technique. Tongue-in-groove causes retraction and stiffness; the strut causes loss of rotation and projection of tip. We introduced a novel technique that avoids these consequences. Between February 2018–February 2019, 40 female underwent primary rhinoplasty. Mean age: 27 years (18–41 years). Follow-up:1–2 years. In first group (20 patients), caudal septum was resected and strut was not fixated to caudal septum. In second group (20 patients), tongue-like extension (septal autoextension) was preserved at caudal septum and sutured to strut. Preoperative, peroperative, and postoperative images were compared. Tip projection ratio calculations, nasolabial angle measurements were evaluated by statistical analyses. The change in projection ratios between peroperative period and 1-year postoperative period of strut-only group was higher than septal autoextension group (p = 0.001). This result indicates that nasal tip projection loss in strut-only group was higher compared to septal autoextension group. The change in nasolabial angle measurements from peroperative period to 1-year postoperative period differed significantly between two groups (p = 0.001). Significant difference was observed between 1-year postoperative nasolabial angle measurements of two groups (p = 0.006); septal autoextension group measurements were higher than strut-only group. These results showed that fixation of strut graft to the septal autoextension provides better preservation of the nasolabial angle and stabilization of nasal tip projection. Fixation of septum and strut graft through septal autoextension provides satisfactory stabilization of tip projection and rotation without stiffness or rigidity.

The plunging nasal tip is a challenging condition because, although it is predominantly a dynamic deformity which occurs during smiling, it also indicates a structural problem. When a person smiles, the paired depressor septi nasi muscles pull the tip caudally at the same time as the levator labii superioris alaeque nasi muscles pull the alar base and lateral lip cephalically. This movement causes straightening of the alar rim. Even though surgical rhinoplasty is the gold standard to restore nasal appearance, the procedure may fail to treat the dynamic cause of the drooping tip. This article outlines the anatomical concepts that lead to a drooping tip and presents a technique that can treat both the dynamic and structural causes of the drooping tip using hyaluronic acid filler. Cases are also presented that illustrate these concepts. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ptosis of the nasal tip is one of the most challenging aspects of rhinoplasty, and the tongue-in-groove (TIG) and the columellar strut (CST) techniques are the two most common procedures used to improve it. The purpose of this study was to introduce a new modification of TIG, to evaluate the long term results of the modified TIG, and to compare its effect on correction of the nasolabial angle with that of the CST. Eighty patients with droopy nasal tips (all female, aged

Background The tongue in groove technique (TIG) is a useful technique for the correction of the nasal tip projection and the nasolabial angle. The purpose of this study was to determine the utility of this technique for nasal tip rotation and projection correction in the Iranian society. Methods This is a retrospective clinical trial study of 20 patients undergoing open septo-rhinoplasty using TIG technique from January 2017 to August 2019 at the oral and maxillofacial unit of Bu Ali Hospital and private sector. Preoperative and postoperative profile view photographs were compared to assess the changes in tip projection and rotation. Results Fifteen patients (75%) had normal angular size, and 5 of them (25%) were not within the normal range after the surgery. The Fisher exact test showed that this success was statistically significant (P = 0.006). Ten patients (50%) had normal projection size, postoperatively. The Fisher exact test showed that this effect was statistically significant (P < 0.01) Conclusion The study demonstrated the benefit of TIG on the correction of nasal tip projection and rotation.

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.

Facial structure, nasal shape, and aesthetic nasal preferences vary broadly among patients of African descent who seek rhinoplasty. This variation reflects the broad diversity in this ethnic group and is highlighted by lapses in computer vision algorithms in accurately recognizing black faces. Across ethnicities, patients who seek rhinoplasty have similar goals: a reshaped nose that fits their facial features and enhances their facial beauty. Among patients of African descent, there is a particularly strong desire for maintaining nasal features that are ethnically sensitive and culturally congruent. This article discusses the nuances of managing the lower third of the African nose.

Arteriovenous malformation is a vascular malformation with fast-flow shunt from the artery to the vein. Extracranial arteriovenous malformation in the head and neck area is rare disease compared to other vascular malformations such as venous malformation or lymphatic malformation. Extracranial arteriovenous malformations especially on face can cause aesthetic problems, therefore surgeons should consider an importance of cosmetic outcome and choose appropriate treatment plan. We report a case of 51-year-old male who presented with enlarged nasal tip diagnosed arteriovenous malformation. This case showed successful outcome after combination therapy consisted of superselective embolization and surgical resection.

Background In full-thickness nasal defects, the internal lining is perhaps the most challenging aspect of the three layers to rebuild. Nasal damage is usually more concentrated on the tip, soft triangles, alar wings, and columella, but the lateral nasal arteries are often left intact and the damage to the dorsal sidewalls are normally superficial. Methods Twelve patients who required total nasal reconstruction received a forehead flap placement as external coverage and autologous rib cartilage as structural support. Residual normal/superficial scar tissue flaps on the dorsal sidewalls with lateral nasal artery pedicles were mobilized and designed for internal lining repair without creating secondary donor site damage. The flaps were then turned 180° downward and placed between the alar medial angles and the fornix. Results No total lining flap necrosis occurred in all the patients. Partial necrosis occurred on the distal edge owing to overpressure of the nostril splint to the flaps; however, the wounds eventually healed, and the nasal structural integrity was preserved. The patients were satisfied with the aesthetic results and had no complaints of airway stenosis. Conclusions Lateral nasal artery pedicle dorsal sidewall skin flaps are appropriately thick, providing enough nostril circumferential support to improve airway stenosis. It allows sufficient blood supply and creates no extra donor site damage. Blood vessels and skin flaps are often undamaged, thereby allowing maximum application in total nasal reconstruction.

Background Nasal skin defect closures are challenging because the nose is a complex anatomic structure with several subunits, and the nasal tip and ala represent particularly difficult subunits to reconstruct. The traditional full-thickness skin graft (FTSG) is an easy and well-established method, but often results in undesirable outcomes in terms of the nasal contour caused by a lack of dermal tissue. Aims The purpose of the study is to report the outcomes of the simultaneous application of the acellular dermal substitute (Matriderm® ) with FTSG in the treatment of nasal skin defects. Patients/methods Five patients with various nasal skin defects were treated with multilayered Matriderm grafts followed by FTSGs harvested from the pre- or postauricular region. Graft survival, scar quality, and patient satisfaction were evaluated and compared with 10 patients treated with conventional FTSGs. Results One-stage Matriderm-aided FTSGs were well-taken in all cases. Scar quality in the Matriderm group (8.0 ± 1.9) was statistically superior to that in the FTSG only group (10.8 ± 1.7). The Matriderm-aided graft was also superior in patient satisfaction. Conclusions The multilayered application of Matriderm in combination with FTSG is a reliable method for covering nasal skin defects, especially in the thick skin zone of the tip and ala.

The nose plays a crucial role in the human experience, both aesthetically and functionally. The biomechanics of covering flaps, the importance of a firm framework, and the anatomical basis for aesthetic subunits are imperative concepts as one proceeds through the algorithm of reparative options. The subunits consist of three paired units—the ala, soft tissue facets (also known as soft tissue triangles), and sidewall, as well as three unpaired units—the dorsum, tip, and columella. Because many defects cross aesthetic subunits, it is critical to understand when to adapt the subunit principle and how or when to use a combination of techniques. It can be more challenging to apply the subunit principle to small grafts and local flaps of the nose. Convex subunits, such as the nasal tip and alar lobule, more frequently follow the subunit principle. In our practice, we adhere to a teaching of producing “straight lines and sharp corners.” This applies to local flaps and grafts and focuses on keeping scar lines inconspicuous. In this article, we discuss approaches we follow for various defects along with technical pearls for performing these reconstructions. The subunit principle is more of a practice of thinking of resultant scars within a background of existing lines, reflections, and contour inflections.

Background: Nasal tip support mechanism plays an importantrole in maintaining tip in its position and preventingdrooping of nasal tip and nasal lengthening. In rhinoplastysurgery, this mechanism can be excised or detached duringdifferent steps of rhinoplasty, in our practice we detach threeattachments which play an important role in tip support;attachment in-between the caudal septum and foot plates ofmedial crura which can be replaced by medial crural septalsuture, interdomal attachment also can be replaced by interdomalsuturing, while the attachment in-between upper andlower lateral cartilages, which is usually detached duringcephalic trimming of the lower lateral cartilage, is not replacedby any type of suturing technique. In this study, we describeda new intercartilaginous suturing technique to reattach thisattachment with the remaining part of lower lateral cartilage.We aimed to analyze the log-term effect of re-attachment ofthe ligament between upper and lower lateral cartilages ontip support, projection and rotation.Material and Methods: Twenty four patients were includedin this study; group I included 12 patients had underwentaesthetic rhinoplasty surgery without applying intercartilaginoussuture, while in group II, the new suture wasapplied in 12 patients during rhinoplasty. In both groups,nasolabial angle and projection/ nasal length ratio in theprofile view of patients' photographs were measured at 1.5,3 and 6 months post-operatively as well as, patient's satisfactionregarding aesthetic outcome was subjectively evaluated by aquestionnaire at 6 months post-operatively.Results: The study revealed that nasal tip position wasmaintained in group II more than group I in a period of 6months following rhinoplasty surgery with more patientsatisfaction score in group II of patients as well.Key Words: Primary rhinoplasty – Open rhinoplasty

Resumen Objetivo: describir los resultados que se obtienen con el uso de ortopedia prequirúrgica NAM, Dynacleft y componente nasal en relación a estética, alimentación y brecha entre segmentos maxilares. Método : Se realizó un análisis de la literatura publicada utilizando bases de datos Pubmed y SCIELO, además de una búsqueda manual de libros y artículos científicos. Después de aplicar los criterios de inclusión y exclusión, se analizaron 25 estudios. Resultados : La literatura indica que NAM y Dynacleft mejoran la estética y disminuyen la brecha entre los segmentos maxilares, con respecto a la alimentación se necesita mayor evidencia. Conclusión: los resultados obtenidos con la ortopedia prequiríurgica son mejores si se empieza los primeros días de nacimiento. Dentro de la estética destaca la simetría labial y nasal, proyección de la punta de la nariz y cicatriz post operación primaria.

Septal extension graft is a unique technique for controlling nasal lengthening and tip projection, rotation, and shape by which a graft is fixed to the septum, leading to a strong and stable supporting structure. Nasal tip three-dimensional positioning is a vital and difficult component in the overall appearance of the tip. A total of 12 Middle Eastern patients with thick nasal envelope skin were subjected to rhinoplasty using the septal extension graft (SEG) method. Eleven out of the 12 patients, had pleasing results after primary rhinoplasty with SEG, while only one patient had SEG as a secondary procedure. In conclusion, septal extension graft in rhinoplasty is an effective technique for achieving a strong supporting force of the nasal tip for adequate projection. Keywords: Nasal tip, surgery, septal extension, graft, rhinoplasty

Frontonasal dysplasia is an uncommon congenital anomaly with diverse clinical phenotypes and highly variable clinical characteristics, including hypertelorism, a broad nasal root, median facial cleft, a missing or underdeveloped nasal tip, and a widow’s peak hairline. Frontonasal dysplasia is mostly inherited and caused by the ALX genes (ALX1, ALX3, and ALX4). We report a rare case of a frontonasal dysplasia patient with mild hypertelorism, a broad nasal root, an underdeveloped nasal tip, an accessory nasal tag, and a widow’s peak. We used soft tissue re-draping to achieve aesthetic improvements.

Background Primary rhinoplasty outcomes may not meet individual expectations. Consequently, reoperation may be advocated to improve results. This study examines the prevalence of individuals considering revision rhinoplasty, while identifying the main cosmetic and functional complaints and factors associated. Methodology This is a cross-sectional study conducted in Saudi Arabia using a self-reported online questionnaire distributed through social media channels. The sample included 1370 participants who were all Saudi nationals over the age of 16 who had undergone primary rhinoplasty at least 1 year prior. Results The prevalence of individuals considering revision rhinoplasty was 44.7%. The primary reason for considering it was the desire for further esthetic improvement in an already acceptable result (50.16%). The most common cosmetic complaints subjectively reported were poorly defined nasal tip (32.35%). The most prevalent nasal function symptom was nasal obstruction (56.9%). Significant factors associated with considering revision rhinoplasty included the physician not understanding the patient’s complaints, short consultation time, low monthly income, inadequate information about the expected results, not using computer imaging to predict outcomes, lack of rapport with the surgeon, and inadequate information about the risks and complications. Conclusions A thorough understanding of patient concerns and expectations, as well as thoughtful consideration of risk factors, may help surgeons achieve more successful outcomes and potentially reduce the incidence of revision rhinoplasties. Level of evidence III

Rhinoplasty is often performed to narrow the nasal tip. Compared with extensive cartilage excision, scoring, and transaction, suture techniques are a favorable method. Suturing techniques offer favorable esthetic and functional outcomes. However, deformities and unnatural appearances may occur if sutures are overtightened or placed incorrectly, and it is possible to inadvertently narrow the external nasal valve and invert the caudal sides of the lateral crura. In this retrospective study, author analyzed the functional and esthetic outcomes of a novel suture method developed to support the external nasal valve by caudocephalic rotation of the lateral crura. The outcomes of the lateral crus caudocephalic rotation suture (CC suture) method were assessed in 24 patients (22 females, two males; age 18–43 years) who underwent primary septorhinoplasty and had iatrogenic or genetic inversion of the caudal sides of the lateral crura. The patients were followed up for 12–36 months. During this time, no serious complications were noted in any patient, and there was no requirement for revision surgery. Satisfactory or acceptable results were obtained in all patients. The CC suture technique is a simple, reversible, and nondestructive technique that benefits from minimal graft use, decreased operation time, improved function and cosmesis, and a short learning curve. Level of evidence: Level V, therapeutic study.