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BACKGROUND Shape of the tip is supplied by lower lateral cartilages (LLC) which are divided into 3 crura each composed of 2 segments divided by junction lines (JL). Tip restoration becomes more complicated with the presence of angulation deformities (AD) over LLC. It is aimed to classify AD based on their relationship to JL, to clarify their causes of the formation and to discuss restoration techniques for each of them. MATERIAL AND METHODS Between 2016 and 2018, 375 primary rhinoplasties have been performed. All types of the AD have been retrospectively determined, renamed. Six different types of AD have been encountered in this series. Four of AD (types A, B, C, and D) have been located over JL and 2 of AD (types S and T) have not been located over JL. RESULTS Type-A AD diverging the footplates were observed in 9 patients, type-B AD resulting in a boxy-nose were observed in 18 cases, type-C AD resulting in acute angulation of the dome at the medial genu were observed in 4 patients, type-D AD resulting in a pinched tip and concave alar wings were observed in 6 patients, type-S AD resulting in a weak, and short columella were observed in 5 patients, type-T AD that creates a bulge over ala was observed just in 1 patient in our series. The total number of patients with AD was 39 (10.4% of all cases). CONCLUSION Classification of AD over LLC based on their relationship to certain JL provides ease for recognition of these deformities and immediate per-operative planning for their restoration.

BackgroundKabuki syndrome (KS) is a clinically recognisable syndrome in which 70% of patients have a pathogenic variant in KMT2D or KDM6A. Understanding the function of these genes opens the door to targeted therapies. The purpose of this report is to propose diagnostic criteria for KS, particularly when molecular genetic testing is equivocal.MethodsAn international group of experts created consensus diagnostic criteria for KS. Systematic PubMed searches returned 70 peer-reviewed publications in which at least one individual with molecularly confirmed KS was reported. The clinical features of individuals with known mutations were reviewed.ResultsThe authors propose that a definitive diagnosis can be made in an individual of any age with a history of infantile hypotonia, developmental delay and/or intellectual disability, and one or both of the following major criteria: (1) a pathogenic or likely pathogenic variant in KMT2D or KDM6A; and (2) typical dysmorphic features (defined below) at some point of life. Typical dysmorphic features include long palpebral fissures with eversion of the lateral third of the lower eyelid and two or more of the following: (1) arched and broad eyebrows with the lateral third displaying notching or sparseness; (2) short columella with depressed nasal tip; (3) large, prominent or cupped ears; and (4) persistent fingertip pads. Further criteria for a probable and possible diagnosis, including a table of suggestive clinical features, are presented.ConclusionAs targeted therapies for KS are being developed, it is important to be able to make the correct diagnosis, either with or without molecular genetic confirmation.

OBJECTIVE Evaluate treatment of patients with bilateral cleft lip operated during the last 10 years, using the methodology of Mortier and Anastassov. METHODS A total of 84 patients were evaluated using a preoperative score assessing fissure severity and a postsurgical score assessing of uncorrected or secondary deformities. A pre- and postcorrelation analysis was performed to evaluate the gain and identify the main postoperative alterations, using Spearman's statistical test (P < 0.001). RESULTS About 89.3% underwent surgery between 4 and 7 months. Surgical techniques used Millard 65.5% and Mulliken 34.5%. Presurgical evaluation classified fissures as mild (0%), moderate (2.4%), severe (19.1%), or very severe (78.6%). Postoperative evaluation classified results as poor (24%), satisfactory (12%), good (15, 6%), very good (34.6%), or excellent (14.3%). The postoperative changes on the lip were the notch in the vermilion and the defect in the edge of the vermilion, and in the bow of the wide cupid; in the nose, the most frequent were deficiency in the upper nasal nostril, insufficient rotation of the alar base, broad tip, and short columella; in the scar and alveolar portion, the most frequent were alveolar cleft, premaxilla protrusion, and poor scar. Spearman correlation of preoperative and postoperative was positive of 0.43. CONCLUSION The proposed measurement method is technically simple and can be performed without equipment allowing pre- and postoperative evaluation to identify the main alterations to be corrected.

To correct an Asian short nose with low dorsum, short columella, and poorly defined nose tip, augmentation rhinoplasty has been popularized. A simple augmentation no longer is considered an efficient rhinoplasty approach for Asians aesthetically; most surgeons simultaneously perform nasal elongation and augmentation during rhinoplasty. To extend the nose length successfully, important factors are cartilages, mucosal and skin conditions, and presence and degree of fibrotic changes. In addition, surgeons should consider preoperatively how much should be extended from an aesthetics perspective. This article introduces the current practice of surgical correction of the short nose in Asians.

Objective: Nasal stigma in patients with bilateral cleft lip and palate (BCLP) are a short columella and a flattened nasal tip. Design: The aim of this study was to evaluate the aesthetics of adolescents with BCLP, operated with a modified Cutting primary columella lengthening technique, associated to a modified Grayson orthopedic nasoalveolar molding (NAM). Setting and Patients: 72 BCLP patients were operated with this approach. Standardized photographic records were taken every 2 years. A group of 23 patients between 12 and 13 years of age was compared through normalized photogrammetry to a matched control of 23 noncleft adolescents. Results: Nasal protrusion and length of the columella were very close to normal. On the other hand, nasolabial angle and interalar width were still excessively wide compared to the noncleft sample. Conclusions: NAM and primary columella lengthening in BCLP has allowed to avoid traditional secondary columella lengthening at 5 to 6 years of age and given the patients a more pleasing, near-normal nasolabial appearance until adolescence. Some of the patients will require correction of the nasal width at a later stage.

The mature bilateral cleft nasolabial deformity exhibits prolabial and vermilion deficiency, a broad depressed nasal tip, and short columella. Many strategies attempt to correct these stigmata, with varying degrees of success. The purpose of this communication is to describe a novel sequenced approach, staging an Abbe flap and rhinoplasty, with morphometric analysis of results. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Bilateral cleft lip/cleft palate is associated with nasal deformities typified by a short columella. The presurgical nasoalveolar molding (NAM) therapy approach includes reduction of the size of the intraoral alveolar cleft as well as positioning of the surrounding deformed soft tissues and cartilages. In a bilateral cleft patient, NAM, along with columellar elongation, eliminates the need for columellar lengthening surgery. Thus the frequent surgical intervention to achieve the desired esthetic results can be avoided. This article proposes a modified activation technique of the nasal stent for a NAM appliance for columellar lengthening in bilateral cleft lip/palate patients. The design highlights relining of the columellar portion of the nasal stent and the wire-bending of the nasal stent to achieve desirable results within the limited span of plasticity of the nasal cartilages. With this technique the vertical taping of the premaxilla to the oral plate can be avoided.

The treatment of nasomaxillary hypoplasia is challenging. The phenotype of Binder "syndrome" includes the following: midfacial hypoplasia, class III malocclusion, small or absent anterior nasal spine, flattened nose, horizontal nostrils, short columella, acute nasolabial angle, and a flat frontonasal angle. A staged approach is used, with orthognathic surgery to achieve vertical maxillary length and sagittal advancement, followed by rhinoplasty aimed to increase nasal tip projection, rotation, and columellar length. This article details the diagnosis and treatment of nasomaxillary hypoplasia, demonstrating the senior author's (D.M.S.) preferred approach and technical steps.Therapeutic, V.

Objectives The bilateral cleft nasal deformity is characterized by a short columella and a broad, flattened nasal tip. Secondary correction is challenging and often complicated by skin envelope scarring and hypoplastic alar cartilages. Adequate and durable tip projection requires a procedure that adequately augments the nasal tip and maximizes tip support. We describe a novel technique for secondary correction of this deformity in the immature pediatric population. Methods The conchal butterfly graft technique utilizes a folded cartilage construct to simultaneously increase tip projection and provide tip support. A retrospective review of 19 consecutive patients with bilateral cleft lip who underwent secondary tip rhinoplasty utilizing our technique over a 7-year period was conducted. Charts were reviewed for age at operation, length of follow-up and secondary revision procedures. Pre- and post-operative photographs were compared using two different methods to assess the degree of change and overall aesthetic result. Three plastic surgeons who previously were unfamiliar with the technique independently rated seven nasal tip characteristics. Nasal tip projection (NTP) was then measured objectively by two widely utilized methods: the Goode method and the Baum method-modified by Powell. Results Long lasting correction of the bilateral cleft nasal deformity was achieved utilizing this technique in 19 patients over a 7-year period with a mean length of follow-up of 5.4 years. We demonstrate augmented nasal tip projection that approaches ideal relationships from both relative measurement and survey data. Conclusion The conchal butterfly graft technique is effective for reconstruction of the bilateral cleft nasal deformity, and in our experience, has resulted in long lasting nasal projection and overall improved facial balance.

The projecting premaxilla in case of bilateral cleft lip and palate presents a great challenge to the surgical repair of the cleft lip due to difficulty in suturing the large defect. Furthermore, the short columella and nasal dysmorphology result in compromised esthetics even with repeated surgeries. The current case report describes the use of an expansion screw for retraction of cleft premaxilla prior to surgical repair along with nasal molding in a 5-month-old infant.

Open rhinoplasty and Abbe flap techniques are traditionally useful tools for the reconstruction of secondary bilateral cleft lip nasal (BCLN) deformity. We aimed to investigate the long-term outcomes of simultaneous columella and philtrum reconstruction using prolabial flap combined with Abbe flap in secondary BCLN deformity. From January 2009 to July 2014, 26 patients (17 males and 9 females; mean age 21 years) with secondary BCLN deformity were recruited. All patients had severe short columella and philtrum deficiency. The whole superiorly based prolabial flap was harvested and trimmed for columella reconstruction. An Abbe flap from the central lower lip was elevated to reconstruct the esthetic philtral unit. No flap necrosis occurred postoperatively. The average follow-up was 2.7 years. The columella length was 4.7 ± 1.3 mm preoperatively and 10.4 ± 2.1 mm postoperatively. The philtrum length increased to 14.4 ± 2.6 mm postoperatively from a preoperative 8.9 ± 2.4 mm. Regarding the overall impression of the reconstruction, 22 patients ranked it as very good or good. In secondary BCLN deformity, the prolabial flap combined with Abbe flap technique is an effective alternative for the treatment of severe short columella complicated with severe philtrum deficiency.

Background This article presents long-term outcomes after correcting secondary bilateral cleft lip nasal deformities using a refined reverse-U incision and V-Y plasty or in combination with a composite graft in order to elongate the short columella. Methods A total of forty-six patients underwent surgery between September 1996 and December 2008. The age of the patients ranged from 3 to 19 years of age. A bilateral reverse-U incision and V-Y plasty were used in 24 patients. A composite graft from the helical root was combined with a bilateral reverse-U incision in the 22 patients who possessed a severely shortened columella. The follow-up period ranged between 2 and 10 years. Results A total of 32 patients out of 46 were evaluated postoperatively. The average columella length was significantly improved from an average of 3.7 mm preoperatively to 8.5 mm postoperatively. The average ratio of the columella height to the alar base width was 0.18 preoperatively and 0.29 postoperatively. The postoperative basal and lateral views revealed a better shape of the nostrils and columella. The elongated columella, combined with a composite graft, presented good maintenance of the corrected position with no growth disturbance. A composite graft showed color mismatching in several patients. Twenty-six patients demonstrated no alar-columella web deformity and satisfactory symmetry of the nostrils. Four patients experienced a drooping and overhanging of the corrected alar-columella web. Conclusions A bilateral reverse-U incision with V-Y plasty or in combination with a composite graft was effective in correcting secondary bilateral cleft lip nasal deformity.

For secondary repair of a bilateral cleft lip deformity with a short columella and defective upper lip, simultaneous correction of the lip and nose is ideal. We perform a nasal repair through a bilateral reverse-U incision and columella elongation using the upper lip. An Abbé flap is then transferred to the upper lip defect. This procedure enables total reconstruction of characteristic bilateral cleft lip deformities in one stage. We have applied this method to 15 patients (9 males and 6 females) with an average age of 18.7 years. Although some patients need jaw surgery, all have been satisfied with the results.

Rhinoplasty in patients of Asian descent presents a different set of challenges for rhinoplasty surgeons. Most Asian noses are characterized by a thick skin envelope, low radix and dorsum, bulbous tip, weak lower lateral cartilages, and a short columella. In this article, the authors describe an autogenous approach to Asian rhinoplasty that achieves aesthetic results comparable to the use of silicone implants without the associated risks observed with alloplastic implants. The technique consists of the following: (1) harvesting of grafts, (2) an open approach with skin defatting, (3) septal harvest, (4) placement of a septocolumellar graft, (5) nasal tip refinement, (6) radix and dorsal augmentation, (7) osteotomies, (8) alar base modifications, and (9) closure and casting.

To elevate the nasal tip in Orientals, two simple adjunctive procedures are presented. Either V-Y advancement or earlobe composite graft can be used after the open rhinoplasty incision on the columella-labial junction. Over the past 6 years, 62 Oriental patients with short columella were treated with one of the above procedures. The nasal tip projection as well as nasal tip appearance greatly improved. The scar in the columellar base posed no problems, and none of the patients complained about the scar. The procedures are particularly useful for cosmetic rhinoplasty in Orientals as well as in cleft lip nasal deformity.

The most common and striking feature of the bilateral cleft lip nose deformities is a short columella. This problem can be resolved by lengthening the columella. In this article the authors lengthen the columella using the interdigitation of triangular flaps in the upper lip tissue. The columellar elongation is made by an advancement of nostril tissue and an interdigitation of the triangular flaps. Our method shows good aesthetic results. The triangular flaps that are intersected without excision make the columellar base pyramidal and medially directs the alar bases, narrowing the width of the nostril sills. Though the optimal columellar lengthening procedure can vary according to the deformed anatomy of the nose and lip, this method deserves to be considered especially in patients who have sufficient tissue in their nostril sills.

The Asian nose is characterized by a flat nasal bridge, indistinct dorsal aesthetic line, an underprojected and broad nasal tip, and a short columella. Cosmetic procedures to enhance these features are popular in Asians and surgical rhinoplasty is the therapeutic gold standard for individuals seeking to enhance the appearance of their nose. However, in recent years, there appears to be an increasing number of Asians seeking nonsurgical rhinoplasty and this tendency is seen in both primary and revision cases. The biggest strength of filler rhinoplasty is that it is minimally invasive, has a good safety record, provides immediately visible results, and can be done conveniently in the office setting without the downtime of surgery. Despite its temporary longevity, it is popular because it is simple, effective, and economical. This article describes a “structured” nonsurgical Asian rhinoplasty approach using dermal fillers that can produce a comprehensive cosmetic enhancement of the Asian nose.

A short columella is one of the most severe problems in bilateral cleft lip and nose deformity. In particular, with tissue insufficiency or scar contracture on the upper lip, it is very hard to achieve a good nasal profile with conventional methods.One hundred thirty-seven patients with a short columella were operated on from February of 1987 to December of 2008. The average age at operation was 7.3 years. The conchal cartilage was harvested. The preauricular or postauricular skin-subcutaneous fat composite tissue was harvested. Through a transcolumellar incision, the conchal cartilage was inset and the defect was covered with skin-fat composite tissue. The serial nasal profiles were evaluated before and after surgery. Also, the postoperative nasal profiles were compared with normal profiles. The postoperative color difference with surrounding skin was measured by the L*a*b* photographic analysis method.The mean height and width of skin-subcutaneous fat composite tissue were 9.81 and 22.14 mm, respectively. The preoperative and postoperative measuring for columella height was 5.1 + or - 1.1 mm and 14.2 + or - 1.5 mm. The columella-lip angle was 120.30 + or - 12.97 preoperatively degrees and 98.76 + or - 10.98 degrees postoperatively, whereas the angle of columellar-alar triangle was 111.56 + or - 11.39 degrees and 97.91 + or - 11.49 degrees, respectively. None of the postoperative profiles were different from those of normal Korean people of the same age except in the 0- to 6-year-old group (p0.05). The color match was best with preauricular composite tissue. Complications included total necrosis in three cases and partial necrosis in 12 cases that were treated conservatively.Elongating columella using a composite graft can be a satisfying alternative, especially for a severe short columella with upper lip tissue deficiency.

The mobilization of two muco-chondrocutaneous flaps obtained by two parallel incisions along the nasal dorsum may elevate and elongate the columella in patients with bilateral cleft lips. The nose tip is also modulated by a triangular tissue resection right above the alar segment in both sides. Thirty-four patients have been treated with this method.

Bilateral cleft lip-cleft palate is associated with nasal deformities typified by a short columella. The authors compared nasal outcomes of cleft patients treated with banked fork flaps to those of patients who underwent nasoalveolar molding and primary retrograde nasal reconstruction.A retrospective review of 26 consecutive patients with bilateral cleft lip-cleft palate was performed. Group 1 patients (n = 13) had a cleft lip repair and nasal correction with banked fork flaps. Group 2 patients (n = 13) had nonsurgical columellar elongation with nasoalveolar molding followed by cleft lip closure and primary retrograde nasal correction. Group 3 patients (n = 13) were age-matched controls. Columellar length was measured at presentation and at 3 years of age. The number of nasal operations was recorded to 9 years. The Kruskal-Wallis and Tukey-Kramer tests were used for statistical analysis.Initial columellar length was 0.49 +/- 0.37 mm in group 1 and 0.42 +/- 0.62 mm in group 2. Post-nasoalveolar molding columellar length was 4.5 +/- 0.76 mm in group 2. By 3 years of age, columellar length was 3.03 +/- 1.47 mm in group 1, 5.98 +/- 1.09 mm in group 2, and 6.35 +/- 0.99 mm in group 3. Group 2 columellar length was significantly greater (p0.001) than that of group 1 and not statistically different from that of group 3 (p0.05). All group 1 patients (13 of 13) needed secondary nasal surgery. No nasoalveolar molding patients (zero of 13, group 2) required secondary nasal surgery.Nonsurgical columellar elongation with nasoalveolar molding followed by primary retrograde nasal reconstruction restored columellar length to normal by 3 years and significantly reduced the need for secondary nasal surgery.

The incus once removed at the first stage can be used in ossicular reconstruction at the second stage, when it is preserved appropriately. The present study was conducted to investigate if the mastoid bowl is a suitable site for storage. The study group included 24 ears of 23 patients who underwent staged tympanoplasty for the treatment of middle ear cholesteatoma. The average interval between the two stages w as 8.3 months (range 6–12 months). The incus was identified in all cases at the second stage: ten incudes were found to be covered with a thin mucosa layer, 12 were buried in fibrous or granulation tissue, and two were joined to the surrounding bone. In 19 cases, the incus was available as a short columella for ossicular reconstruction. The r emaining five cases were reconstructed using a hydroxyapatite ossicle as a long columella, since the stapes superstructure was missing at the second stage. Preservation of the incus in the mastoid bowl is an effective option in staged tympanoplasty, when the incus is considered useful for ossicular reconstruction at the second stage.

Background: Various methods for primary repair of bilateral cleft lip have been developed, but they often produce inadequate results, such as an upturned nose or a short columella. We perform primary lip repair with muscle reconstruction to correct depression of the nasal floor and inferoposterior displacement of the alar base. Then, open rhinoplasty to project the nasal tip is performed during childhood. This article describes the methods and results of open rhinoplasty for bilateral cleft lip patients. Methods: Open rhinoplasty with a modified forked flap is performed. The harvested conchal cartilage is grafted as a strut to strengthen and extend the septum. The lower lateral cartilages are sutured to the grafted cartilage and fixed in the correct position. Before skin closure, the tips of the 2 V flaps of the forked flap and the reverse V-flap between the forked flap are trimmed. Three trapezoidal flaps are sutured to the base of the columella. Thirty patients with bilateral cleft lip nasal deformities have undergone surgery. The operative results of 15 of 30 patients were evaluated photogrammetrically. Results: The nose was refined and more projected. The nasolabial angle and the nasal tip projection were improved. The reformed configuration was well maintained for many years. Photogrammetric analysis demonstrated increases in both the nasal height-to-width ratio and the nostril height-to-width ratio and a decrease in the nasolabial angle. Conclusions: Open rhinoplasty during childhood using 3 trapezoidal flaps and conchal cartilage graft improves bilateral cleft lip nasal deformities effectively.

Paintings and drawings by Lucas Moser, Leonardo da Vinci, Albrecht Durer, and Jacob Cornelisz van Oostsanen suggest that they employed people who had had cleft lips operated on as models for their works of art. Created between 1431 and 1520, the portraits show diagnostic facial profiles with a curved nasal dorsum, short columella, maxillary retrusion, and pseudoprogenia. The first medical illustration of cleft lip surgery was published in 1564 by Ambroise Pare. It was therefore late Gothic and Renaissance artists who depicted the conspicuous signs of surgically treated patients with cleft lip more than 130 years before the surgeons.

The surgical results of ossicular chain reconstruction using a hydroxyapatite prosthesis were evaluated in 106 ears of 101 patients who were followed up for > 5 years. Successful reconstruction was defined as: (1) postoperative air-bone gap of

We report on three brothers, aged 6, 3, and 2 years, with a hitherto undescribed combination of microcephaly, facial abnormalities, micromelia, and mild mental retardation. Their facial abnormalities included a forehead with bitemporal constriction, upslanting palpebral fissures, synophrys, a short nose with anteverted nostrils, a short columella, a cupid bow-shaped, thin vermilion border of the upper lip, and micrognathia. Their mother had similar clinical manifestations, but was of normal intelligence. The disease was apparently transmitted in a dominant fashion.

While a complete anatomical/ethnographical nasal study of all the different races with every possible variation within the groups might be interesting, I have limited myself to three non-Caucasian groups who commonly request rhinoplasty: Asians, blacks, and Hispanics, with a special emphasis on the black nose. Again, understanding black nasal anatomy is the key to attaining facile comprehension and good surgical technique for most ethnic rhinoplasties.

We report on a 9-month-old girl with an interstitial duplication of 19p, developmental delay, and multiple anomalies including bifrontal prominence, obtuse frontonasal angle, short columella, additional midline philtral pillar, midline ridge on the tongue, vertical midline ridge at the mental symphysis, and a complex congenital heart defect including severe branch pulmonary artery stenosis, secundum atrial septal defect (ASD), and several ventricular septal defects (VSDs). Use of fluorescent in situ hybridization (FISH) with chromosome 19-specific probes showed a direct duplication of bands 19p13.13 and 19p13.2.

We have attempted to change the two scar lines of bilateral cleft lip repair into one zigzag scar line. The prolabium is used to push up the columella and the nasal tip. The donor site of the prolabium is closed by transposition of the nasolabial flap. The postoperative scar shows one zigzag line at the center of the lip. This method has many advantages including an inconspicuous scar, repair of the short columella and flat nasal tip, repair of a wide nose, and repair of the whistling deformity. Complications of this method are maxillary retardation, long lip deformity, and keloid formation. However, these can be avoided by modifying the method.

Nasal deformities in unilateral cleft patients require more-or-less modifications of the nasal tip. The techniques of Goldman and Ponti that have been recommended initially for esthetic rhinoplasties in non-cleft noses include the vertical transection of the alar cartilage on both sides. The first technique is performed in noses that require an extensive modification, especially in large noses with thick seborreic skin, with a short columella or a distinct asymmetry. The second technique is utilized for slight deformities with thin skin, nearly symmetric and a sufficient columella length. Both techniques have proven to obtain good results, also in cleft nose surgery. The operative steps of the techniques are described and some case reports are presented. Finally, a gradual schedule for the cleft nose repair is discussed and the advantages of the techniques described are pointed out.

From 1974 to 1984 we have performed operations on 142 patients with bilateral cleft lip using the Manchester method. Presurgical oral orthodontics were given to 84 patients out of 142. We used a head cap with elastic band and oral appliance which was devised by Dr. J. H. Peat. Experience proves that the earlier presurgical oral orthodontics was begun, the more more satisfactory were the results. Treatment of our cases was started as early as at approximately 4-6 weeks of age. The average length of treatment was 8 weeks, and the patients were opearated on at the age of 3-5 months. Post operative results in almost all of our cases were satisfactory. The advantages were 1) lip with satisfactory lenght, 2) acceptable scar pattern, 3) free prolabium and deep gingiva-labial sulcus. However, several problems to be overcome in our cases were remained. These problems appeared severely depending on the degree of congenital deformity. Secondary repair to the extremely depressed nose and short columella was performed at the age of 4-6 years. In these cases we made a forked flap on the upper lip and elongated a short columella while at the same time repairing the wide cupid's bow.

We report on a family in which the propositus and two distant relatives have a wide nose, broad philtrum, and short columella, a fusion defect of the medial nasal processes. This anomaly resembles potato nose [Benjamins and Stibbe, Acta Otolaryngol 11:274-284, 1927] and bifid nose [Anyane-Yeboa et al, Am J Med Genet 17:561-563, 1984], which are also fusion anomalies of the medial nasal processes. Potato nose is an autosomal dominant trait, whereas bifid nose is likely heterogeneous. In this family autosomal recessive inheritance is likely, therefore suggesting that anomalies of the medial nasal processes are causally heterogeneous and represent a developmental field defect.

The noses of 34 attractive young North American Caucasian women were analyzed quantitatively, based on 19 nasal measurements (6 single and 7 paired linear measurements, 3 angles, and 3 inclinations) and 15 craniofacial measurements (10 linear measurements and 5 inclinations) taken directly from the face of the women. The relationship between the nasal measurements was studied in 16 proportion indices and the relationship between the nasal and the other craniofacial measurements in 13 interareal indices. The findings were also compared with those in 21 women with below-average faces. Two types of facial harmony disruption were identified: disharmony, a normal index with a visually apparent failure of proportionality, and disproportion, an index value outside of the normal range. The percentage of disharmonies and disproportions was significantly higher in the group of 21 women with below-average faces. The study revealed a wide variety of "ideal" noses. Only a small portion of the measurements (12%) and proportion indices (7%) were at the mean value. At least two-thirds of the interareal proportion indices were located in the mean +/- 1 standard deviation portion of the normal range. Only about one-fifth of the interareal indices were disharmonious and 2.8% disproportionate. The disproportions were more areal in the attractive faces and more interareal in the below-average faces. The greatest disproportion in the attractive face was the moderately short columella in relation to the tip protrusion and in the below-average face the long nasal bridge related to the upper-lip height. Disproportions were associated with combinations of normal and abnormal measurements, or with two normal measurements of unequal quality, which resulted in a slightly smaller disfigurement. Analysis of ethnic and racial differences showed the soft nose as the main feature of the most characteristic differences. The study revealed that the key to restoration of facial harmony is the renewal of the uniformity of proportion index qualities by elimination disharmonies and/or disproportionate relationships.

A family is described in which craniosynostosis is associated with characteristic pinnae, a short columella, and symmetrical syndactyly of the fourth and fifth toes, inherited as an autosomal dominant condition. Various dominantly inherited syndromes involving craniosynostosis have been identified, but the constellation of findings in this family suggests a new syndrome different from those previously described.

The difficulties in obtaining an adequate result in the Negroid nose have been elucidated by other authors. Paucity of lobular cartilage; the flat dorsum; short columella; wide flaring nares; and skin that tends to keloid formation have led many surgeons to attempt radical surgical techniques to obtain rather limited results. To circumvent the complications in the more radical procedures, a more conservative concept of an entirely intranasal operation without external skin incisions is outlined. This technique consists of tip rotation and lobular cartilage trimming; the use of a non-absorbable basal bunching suture, and the placement of a dorsal implant without performing osteotomies. A comparison with other techniques is made, as well as surgical aims, limitations and a discussion of results. Pertinent illustrations and photographs are presented.

A successful rhinoplasty demands as much acumen in diagnosis as excellence in technique. For instance, failure to recognize the presence of an anatomic peculiarity (such as a short columella) may vitiate the most carefully elaborated craftsmanship. To bring the above statements into sharper focus, we will discuss postoperative dropping of the nose. In the reduction of nasal length * it is essential to produce an appropriate angle between the nasal base and the lip. This is achieved by tilting the lower nasal component upward and backward (cephalodorsally). To carry out the elevation of the lower component without tilting leaves the angle between the nasal base and the lip unaltered, causing a retracted columella, an overhanging tip, and a snub-nose (pugnose) effect—a deformity more unsightly than that produced by the excessive length 3 (Fig. 1). To use Rethi's 4 simile