Jack P. Gunter

Lateral crural strut graft: technique and clinical applications in rhinoplasty.

&NA; The lateral crural strut graft is a new, versatile technique for reshaping, repositioning, or reconstructing the lateral crura. These grafts are strips of autogenous cartilage that are sutured to the deep surface of the lateral crura. Lateral crural struts are useful in the correction of the boxy nasal tip, malpositioned lateral crura, alar rim retraction, alar rim collapse, and concave lateral crura. We describe the surgical technique and demonstrate representative results of our experience with these grafts in 118 patients.

Internal stabilization of autogenous rib cartilage grafts in rhinoplasty: a barrier to cartilage warping.

Autogenous rib cartilage grafts have gained more widespread use in rhinoplasty as dorsal onlay grafts and columellar struts. However, the usefulness of rib as a donor site has been limited by difficulties with postoperative cartilage warping. We hypothesized that the internal stabilization of rib cartilage grafts with Kirschner wires would prevent warping. The costochondral cartilages of a fresh cadaver were harvested and carved into 4 x 10 x 40 nm blocks. A single 0.035-in K-wire was placed longitudinally into the center of each of the study specimens (n = 9), whereas no internal stabilization was utilized in the control group (n = 9). Over a 10-day study period, a mean of 2.2 degrees of warping was observed in the grafts with K-wires as compared to 8.9 degrees in the control group. This indicates that internal stabilization of rib grafts significantly reduces warping (p < 0.001). In a subsequent clinical study, 28 patients underwent placement of internally stabilized columellar struts (n = 19) and/or dorsal nasal grafts (n = 12) using autogenous rib cartilage. At a mean follow-up of 13.5 months (range 3 to 36 months), graft warping was not observed in any patient. Satisfactory aesthetic results were achieved in all but one patient, in whom mild displacement of a dorsal onlay graft occurred. Palatal extrusion of the K-wire occurred in 3 of the first 9 columellar struts. This prompted an alteration in technique with no subsequent extrusions. We conclude that the internal stabilization of autogenous rib cartilage grafts with K-wires effectively prevents graft warpage.

Aesthetic analysis of the eyebrows.

&NA; Advances in surgical techniques and instrumentation have led to an increased popularity of brow‐lifting procedures. However, because of patient variability and differing surgeon opinions, eyebrow aesthetics and thus surgical goals remain to be clearly defined. We performed an in‐depth evaluation of current eyebrow aesthetics using two study groups. Popular fashion models were evaluated and compared with our own patient population. Important differences in eyebrow position and shape between these groups are delineated and the surgical implications defined. Criteria that contribute to the aesthetics of the eyebrow are reviewed, and guidelines to optimize surgical results and avoid potential complications are discussed. (Plast. Reconstr. Surg. 99: 1808, 1997.)

External approach for secondary rhinoplasty

A systematic approach, using the external rhinoplasty technique, is presented to aid the plastic surgeon in obtaining improved aesthetic and functional results in patients with postoperative nasal deformities. In over 100 external rhinoplasties, there were no problems with the stairstep transcolumellar incision used to provide complete visualization of the underlying nasal framework. The external approach allows for a more accurate intra-operative anatomic diagnosis and subsequent complete correction of the nasal deformity. Three case reports are presented to demonstrate the indications and versatility of the external approach in secondary rhinoplasty.

Augmentation rhinoplasty: dorsal onlay grafting using shaped autogenous septal cartilage.

We describe our experience with autogenous septal cartilage onlay grafts for augmentation of the nasal dorsum in primary and secondary rhinoplasty cases. After careful nasofacial analysis, the grafts are custom-shaped into inverted-V-frame, A-frame, or inverted-U-frame grafts, depending on the type and degree of augmentation desired. The dorsal elevation is thus tailored to fit the imperfection at hand, resulting in a smooth, natural-looking nasal contour. The indications for each type of graft are reviewed, and the surgical technique of graft harvesting and carving is detailed and illustrated.

Classification and correction of alar-columellar discrepancies in rhinoplasty

Classification and Correction of Alar-Columellar Discrepancies in Rhinoplasty Jack Gunter;Rod Rohrich;Ronald Friedman; Plastic and Reconstructive Surgery

Correction of the pinched nasal tip with alar spreader grafts

A pinched nasal tip is caused by collapsed alar rims secondary to weak lateral crura. The resulting deformity can be corrected with alar spreader grafts--autogenous grafts of septal or auricular cartilage that are inserted between and deep to the remaining lateral crura to force them apart, propping up the caved-in segment. We describe the surgical technique, indications, and variations in design of alar spreader grafts and present representative results from our series of 38 patients.

The deviated nose: Optimizing results using a simplified classification and algorithmic approach

The deviated nose presents a particular challenge to the rhinoplasty surgeon because, frequently, both a functional problem (airway obstruction) and an aesthetic problem must be addressed. An approach to the deviated nose is presented that relies on accurate preoperative planning and precise intraoperative execution of corrective measures to return the nasal dorsum to midline, restore dorsal aesthetic lines, and maintain airway patency. The principles of correction include wide exposure through the open approach, release of all deforming forces to the septum, straightening of the septum while maintaining an adequate dorsal and caudal strut, restoring long-term support, reducing the hypertrophied turbinates, and performing controlled stable percutaneous osteotomies. An operative algorithm is described that emphasizes simplicity and reproducibility, and case studies demonstrate the results that can be achieved with this approach.

Nasal tip blood supply: An anatomic study validating the safety of the transcolumellar incision in rhinoplasty

The nasal tip blood supply was studied through anatomic dissections and microangiography in 31 fresh cadaver specimens. The lateral nasal artery was present in all specimens, bilaterally in 30 (97 percent) and unilaterally in one (3 percent) and was located in the subdermal plexus 2 to 3 mm superior to the alar groove. The columellar branch of the superior labial artery was visualized bilaterally in 3 specimens (9 percent) and unilaterally in 21 (68 percent), and was absent in 7 (23 percent). Transcolumellar (external rhinoplasty) incisions were performed in 11 of these cadavers prior to dye injection. A consistent crossover flow (100 percent) was seen from the lateral nasal artery arcades to the distal aspect of the transected columellar branches. We conclude that nasal tip blood supply is derived primarily from the lateral nasal arteries, with a variable contribution from the columellar arteries. Collateral flow to the nasal tip may be provided by branches of the ophthalmic artery. The external rhinoplasty transcolumellar incision does not compromise nasal tip blood supply unless extensive tip defatting or extended alar base resections (above the alar groove) are performed.

A simplified transblepharoplasty subperiosteal cheek lift.

Surgical treatment of the aging face is continuing to evolve. Recent emphasis has focused on managing the malar region, specifically ptosis of the cheek pad. Several authors have described techniques for correcting facial aging changes in the midface through an endoscopic approach or transblepharoplasty approach. The latter procedure requires a lateral canthoplasty, which adds technical difficulty and potential complications to the procedure. We have modified these procedures and now perform a simplified transblepharoplasty subperiosteal cheek lift without routine canthoplasty or canthopexy. Sixty patients who had this procedure were evaluated. Analysis of these patients revealed that our simplified approach to transblepharoplasty subperiosteal cheek lift provides excellent correction of midfacial aging changes with a low incidence of postoperative complications. This article describes this technique and reviews our results.