Anatomic reconstruction of the alar cartilages in secondary or revision rhinoplasty

In my October 22, 2012 post i discussed if there is a surgical decision point such as a  50% rule relating to  missing cartilage where some surgeons decide to  rebuild the alar cartilages or other nasal cartilage in general instead of using an assortment of different individual grafts and fillers. While still not knowing the precise answer to that question, the following article which i discovered after writing that article sheds some light on the issue, and it seems a bit more complicated then that. It emphasizes the advantage of anatomic reconstruction of the nasal tip cartilages instead of using nonanatomic cartilage tip grafts.

ANATOMIC RECONSTRUCTION OF THE NASAL TIP CARTILAGES IN SECONDARY AND RECONSTRUCTIVE RHINOPLASTY    Author: Dr. Frederick J. Menick

   Most techniques for secondary rhinoplasty assume that useful residual remnants of the tip cartilages remain but frequently the alar cartilages are missing- unilaterally, bilaterally, completely or incompletely- with loss of the lateral crura, middle crura, and parts of the medial crura. In such severe cases, excision of scar tissue and the residual alar remnants and their replacement with nonanatomic tip grafts have been recommended. Multiple solid, bruised or crushed cartilage fragments are positioned in a closed pocket or solid shield-shaped grafts are fixed with sutures during an open rhinoplasty. These onlay filler grafts only increase tip projection and definition. Associated tip abnormalities (alar rim notching, columella retraction, nostril distortion) are not addressed. Problems with graft visibility, an unnatural appearance or malposition have been noted.

   Fortunately, techniques useful in reconstructive rhinoplasty can be applied to severe cosmetic secondary deformities. Anatomic cartilage replacements similar in shape, bulk, and position to normal alar cartilages can be fashioned from septal, ear and rib cartilage, fixed to the residual medial crura &/or a columellar strut, and bent backward to restore the normal skeletal framework of the tip. During an open rhinoplasty, a fabricated and rigid framework is designed to replace the missing medial, middle, or lateral crus of one or both alar cartilages. The entire alar tripod is recreated. These anatomic alar cartilage reconstructive grafts create tip definition and projection, fill the lobule, and restore the expected lateral convexity, position the columella and establish columellar length, secure and position the alar rim, and brace the external valve against collapse, support the vestibular lining, and restore a nostril shape. The anatomic form and function of the nasal tip is restored. This technique is recommended when alar cartilages are significantly destroyed or absent in secondary or reconstructive rhinoplasty and the alar remnants are insufficient for repair.

   Anatomically designed alar cartilage replacements allow an aesthetically structured skeleton to contour the overlying skin envelope. Problems with displacement are minimized by graft fixation. Graft visibility is used to surgeon's advantage. A rigidly supported framework with a nasal shape, can mold a covering forehead flap ro the scarred tip skin of a secondary rhinoplasty and create a result that may approach normal.

   Anatomic alar cartilage reconstructions were used in 8 reconstructive and 8 secondary rhinoplasties in the last 5 years. Their use in the repair of postrhinoplasty deformities is emphasized. (Plast, Reconstr. Surg. 104: 2187, 1999.)

http://www.drmenick.com/wp-content/uploads/2012/06/PDF%20Anatomic%20Reconstruction%20of%20the%20Nasal%20Tip%20Cartilages%20in%20SecondaryReconstructive%20Rhinoplasty.pdf

My shrinking nostrils: Nasal tip collapse as a result of rhinoplasty

By now  those of you who have been following this site, will be aware of the terms external and internal nasal valve collapse. When thinking of those terms we automatically think of lateral collapsing of the nasal wall towards the septum particularly with inspiration. But when a significant amount of your tip cartilage (the middle and medial crura) are excised during rhinoplasty you will likely notice, as is in my case, that your nostrils are now significantly less projected then they were before your primary nose surgery. In fact the short projection of my nostrils were pointed out to me by a revision rhinoplasty surgeon a few months back. At closer inspection of the base view of my nostrils, I would guesstimate (since i don't have nostril pictures of my original adult pre-operated nose) that my nostrils are close to  half the length of what my  nostril projection was prior to my primary surgery. I have had my tip reduced in all of my three revision rhinoplastys, as well as reduced and reshaped in my primary. My nasal spine was also reduced in one of my revisions. The problem of an overly large  nasal tip was a result of my primary nose surgeon being overly aggressive with my bridge (I had a very large hooked shaped nose), so by overcompensating for that, the surgeon ended up giving me a ski sloped nose with a very long protruding tip... the Cyrano effect  A big cosmetic assessment mistake that was made by my last surgeon was not understanding how to safely bring into balance the longer tip with my scooped out bridge. The safe, smarter but more complex procedure which should have been performed, was to add grafts to my bridge building it up to line up better with  my tip. Another possibility which could of been performed alone or in tandem with the former was to reshape the tip cartilages using sutures and rotate it downward, since I already had some excision to my tip cartilages previously. Unfortunately the surgeon wasn't that experienced or skilled so he decided to opt for quick & easy 'fix'  and aggressively excise the tip cartilages further down, not taking into account all the previous excisions i had. So in essence he was able to achieve the cosmetic goal of reducing the length of my tip, but unfortunately not without major consequences. I don't believe I have tip ptosis at least not a very distinguishable form of it because my tip was already positioned fairly high after my first revision surgery. However it's very likely that the major and minor supporting tip structures have been negatively impacted on, as well as the vascularity of my skin and soft tissue envelope. I would assume that in order to correct my flattened "shrunk" nostrils i would probably require tip projection as well as correcting the lateral collapse I have, to achieve a normal and relatively proportional sized nostrils ( proper ratio's) for the base of my nose. It's also important to recognize that anything which decreases the nasal valve cross sectional area can negatively impact the nasal airway, creating further feeling of nasal obstruction. Even though there's a significant amount of information about reducing flared out nostrils for cosmetic reasons, not much exists for increasing or restoring the size of one's flattened out nostrils due to prior nose surgery's. At least not that I have found online. As far as nasal tip ptosis is concerned I will discuss that in greater detail on another post.

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Growing nasal cartilage in the lab: Engineering of autologous septal cartilage

Well the possibility for those who need extra nasal cartilage in the nose for aesthetic or functional reasons but don't have enough existing nose cartilage, may soon have another option. On a previous post titled, "Regenerative medicine:Re-growing body parts" August 28 2010 I posted a video discussing in particular how a man was able to regrow his finger using a powder, and it discusses tissue engineering in general, however not for nose in particular.  For those that haven't yet read my previous posts; harvesting cartilage from your own body is preferred method of choice for replacing, or strengthening  missing  or weakened cartilage in the nose. For the nose, the gold standard is nasal cartilage from the quadrilateral region of the septum. When there isn't enough remaining cartilage there because of previous surgical removal the surgeon can harvest cartilage or bone from, ribs, ears, cranium, or hips. Other sources can be from cadaver, or use of synthetic materials. All these are inferior choices to your own nasal cartilage and have their own unique set of drawbacks.  However if cells from your nasal cartilage can be isolated and grown in a lab, to grow new cartilage then that would be the ideal. This research has been underway for couple years now at UC San Diego! 

"Researchers at UC San Diego have turned to tissue engineering to develop replacement cartilage for the nose. Dr. Deborah Watson says a small amount of cartilage is removed from the patient’s nose. Technicians isolate the cells from the tissue, then grow the cells to increase their number. The cells are then placed into a three-dimensional matrix, where they will continue to grow in number and form tissue. Enzymes and growth factors are added to encourage growth and formation of a harder tissue.
Watson says it can take two to three months to generate cartilage that is strong enough to place back in the body. The surgeon will fine tune the shape of the cartilage before inserting it back into the nose. The “new” cartilage is either placed inside a pocket of soft tissue or sutured to remaining cartilage in the nose. Once in place, the engineered cartilage will continue to mature and become stronger.
Cartilage tissue engineering is still in testing phases and not yet approved by the FDA. Watson says the process may eventually enable doctors to provide patients who need nasal reconstruction with an aesthetically pleasing and functional nose. Since the cells come from the patient’s own body, theoretically, there is no risk of rejection of the engineered cartilage."

http://www.wsoctv.com/news/news/health-med-fit-science/growing-noses/nG9ST/

http://www.webmd.com/healthy-beauty/video/growing-noses
©noserevisionsurgeryandsurgeons.blogspot.ca

I really hope that researchers will soon conduct tissue engineering of the turbinates as well, for those who suffer from Empty Nose Syndrome. Except for parts of the sexual organs, which is not an option as donor site, there really is no other part of the human body that acts like or resembles the natural vascularness of the turbinates to be used for replacing lost tissue due to over resectioning.  

http://emptynosesyndrome.org/what_is_ens.php