Assessment of Nasal Function After Tip Surgery With a Cephalic Hinged Flap of the Lateral Crura: A Randomized Clinical Trial

529647AESXXX10.1177/1090820X14529647Aesthetic Surgery JournalAmali et al research-article2014 INTERNATIONAL CONTRIBUTION Rhinoplasty Assessment of Nasal Function After Tip Surgery With a Cephalic Hinged Flap of the Lateral Crura: A Randomized Clinical Trial Amin Amali, MD; Amir A. Sazgar, MD; and Mehrdad Jafari, MD Functional and aesthetic nasal surgeries are inextricably linked. This fact has become increasingly evident within the past decade, during which the principle of tissue conservation has permeated the surgical philosophy of reductive rhinoplasty. 1,2 Tissue conservation has been primarily adopted within the domain of dorsal reduction surgery, yet the same principles hold true in tip modification, or tipplasty. 3 For instance, emphasis was once placed on tip reduction techniques that achieved short-term and cosmetic goals often at the expense of harm to the support mechanisms of the tip. As knowledge of the structural and dynamic roles of cartilaginous tip support has grown, a Aesthetic Surgery Journal 2014, Vol. 34(5) 687 695 2014 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: http://www.sagepub.com/ journalspermissions.nav DOI: 10.1177/1090820X14529647 www.aestheticsurgeryjournal.com Abstract Background: Postrhinoplasty nasal obstruction has been ascribed to either postreductive narrowing of the midvault or dynamic collapse resulting from lateral wall insufficiency. Recently, clinicians have reported on various surgical techniques that maximally preserve alar cartilage integrity, unlike the earlier popular methods of tip reduction surgery. Objectives: The authors compared the effects of 2 rhinoplasty techniques: a cephalic trim (CT) of the lateral crura (LC) and a horizontal resection with cephalic hinged flap (HRCH) of the LC of the lower lateral cartilage (LLC). Methods: Fifty-two patients who presented with a bulbous nasal tip deformity were randomly assigned to 1 of 2 groups and underwent either CT of the LC or HRCH. Effects of the procedures were evaluated by both acoustic rhinometry (AR; first and second minimal cross-sectional areas [MCA1 and MCA2, respectively]) and by subjective scoring on a global nasal obstruction visual analog scale (VAS). Assessments were made before and after rhinoplasty. Results: MCA1 and MCA2 were increased after both CT and HRCH. This increase was significant on the right side for both CT (P <.001) and HRCH (P =.001), but the increase on the left side was significant only for HRCH. Conclusions: The improvement noted in breathing quality by VAS and AR suggests that a hinged flap may be effective in reconstructing the internal nasal valve. Level of Evidence: 3 Keywords rhinoplasty, alar cartilage, nasal valve area, cephalic trim, horizontal resection, cephalic hinged flap, lateral crura, tip-plasty, tip modification, acoustic rhinometry Accepted for publication October 21, 2013. better understanding has developed of the consequences that surgical modifications may have on dynamic nasal airflow. 1,2 From the Department of Otorhinolaryngology, Head and Neck Surgery at Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran. Corresponding Author: Dr Amir A. Sazgar, Department of Otorhinolaryngology, Head and Neck Surgery, Vali-Asr Hospital, Imam Khomeini Medical Complex, Tehran University of Medical Sciences, Dr. Gharib Avenue, Keshavarz Boulevard, Tehran 1419733141, Iran. E-mail: asazgar@sina.tums.ac.ir

688 Aesthetic Surgery Journal 34(5) Despite normal conformation of the septum and turbinate, many patients exhibit some nasal obstruction after rhinoplasty. This generally has been ascribed to either postreductive narrowing of the midvault or dynamic collapse due to insufficiency of the lateral wall. 4,5 The internal valve region refers to the area between the caudal end of the upper lateral cartilage (ULC) and the cartilaginous septum and includes the circumferential neighboring structures in the nasal airway. Narrowing at this location can lead to compromised airflow. Lateral wall insufficiency is caused by weakness of the lateral nasal wall, which collapses during negative pressure generation from inhalation. 5-7 The intervalve region refers to the area between the external and internal valves, immediately superior to the lateral crura (LC) of the lower lateral cartilage (LLC) and corresponding to the supra-alar crease. This area is naturally devoid of cartilaginous support and therefore is subject to collapse after tip maneuvers. 1,8,9 Recently, many clinicians have reported on a variety of surgical techniques that maximize the preservation of tip structure. 10-17 Unlike earlier popular methods such as cephalic excision of the LLC, separation of the LLC and ULC, creation of an interrupted strip, and formation of loose or free cartilage edges, these newer techniques have been applied in an effort to reinforce LLC durability and to simultaneously provide aesthetic correction. In the present study, we introduce new modifications for tip-plasty. Instead of reduction surgery, we focus on conservative measures aimed at stabilizing and reorienting the cartilaginous structures and support. 15,17,18 With this technique, the cephalic portion is turned inward as a hinged flap in various ways (rather than cephalic excision of the LC of the LLC), as determined by the specific type of tip deformity, and subsequently is stabilized with nonabsorbable mattress sutures. The cosmetic and anatomic results of these techniques have been presented in earlier studies 15,17-19 ; however, potential effects on the nasal valve area (NVA) warrant additional investigation. In this study, we demonstrate the effects of the hinged flap in the horizontal resection with cephalic hinged flap (HRCH) technique on the NVA, based on subjective (patient self-assessment of global nasal obstruction with a visual analog scale [VAS]) and objective acoustic rhinometry(ar) measures. MEthods This randomized, double-blind, controlled clinical trial was conducted at Vali-Asr Hospital, Tehran University of Medical Sciences, Iran, between March 2011 and February 2013. The study design was approved by the Institutional Review Board and Ethics Committee of Tehran University of Medical Sciences. Fifty-two patients, each of whom provided informed consent for the procedures, were selected for study participation based on inclusion and exclusion criteria by each of the authors in the clinics. All patients were white, and no other ethnicity was represented in this study. Patients with a bulbous tip deformity, defined as an angle of diversion >30 and/or a tip-defining point distance >4 mm, were included in the study and were randomly assigned to receive either cephalic trim (CT; n = 26) or HRCH (n = 26). In all cases, correction of the deformity was performed during open rhinoplasty. Excluded from the study were patients who had undergone revision rhinoplasty, patients with additional deformities (such as saddle nose, rhinosinusitis, and nasal polyposis), and patients with any local or systemic disease that affected the nose and/or paranasal sinuses. Also excluded were patients with more-than-mild septal deviation or deviations that involved the NVA. Surgical Techniques Surgical techniques for both patient groups included routine open rhinoplasty maneuvers such as ULC spreader grafts, medial and lateral osteotomies, and dorsal hump reduction. As previously described for the HRCH technique, 15 the LC and ULC were not separated in the scroll area. The LC and middle crura were demarcated horizontally by 2 lines, and at least 7 to 8 mm of cartilage was preserved caudally. Two horizontal excisions were planned, the width and shape of which were determined by the anatomy and degree of the deformity. A 3- or 4-mm horizontal excision was usually sufficient. The cartilage was incised with a No. 15 scalpel blade, and the cartilage between the 2 cuts was excised and the remnants of the LC of the LLC were preserved. Unlike other techniques featuring turn-in flaps, the skin and mucosal lining inside the ala were not undermined beyond the area in which the cartilage was excised. Next, the cephalic portion was turned in as a hinged flap and stabilized with 5-0 nonabsorbable mattress sutures (Ethicon Endo-Surgery GmbH, Norderstedt, Germany). Three mattress sutures were sufficient to fix the rotated cephalic portion. For the CT technique, the LC and ULC were separated in the scroll area. The cartilage was incised with a No. 15 scalpel blade, preserving at least 7 to 8 mm of cartilage caudally, and the cartilage of the cephalic part was excised. Evaluation AR was performed preoperatively and at least 1 year postrhinoplasty with an A1 acoustic rhinometer (GM Instruments, Kilwinning, Scotland) by 1 physician (A.A.). The patient was seated in an upright position in a quiet room. The temperature in the room ranged from 20 C to 25 C. A round plastic nosepiece with a 13-mm inner

Amali et al 689 diameter and a 7-mm opening was placed. Each side of the nose was measured separately, with care taken to fit the nosepiece tightly to the nostril without distorting the anatomy. Four measurements, obtained at half-second intervals, were taken on each side. The measurements were considered valid if the 4 curves showed no deviation from each other, from the nostril to the end of the C-notch, with a divergence of 20% maximally from the middle curve to the curves posterior end, and no crossover. The data calculated by the A1 acoustic rhinometer software (GM Instruments) were then documented. The physician (A.A.) who performed the pre- and postoperative AR was blinded to which tip-plasty technique was performed on each patient. The first and second minimal cross-sectional areas (MCA1 and MCA2) were measured for all patients. Both preoperatively and 1 year postoperatively, patients self-scored their global nasal obstruction on a VAS from 0 to 10 (0 = no obstruction, 10 = total obstruction). Data Analysis To determine the study s sample size, we consulted a professional biostatistics expert. The sample size was calculated with the power of 80% to include at least 26 subjects in each group. Data were presented as means (± standard deviation [SD]). For each study group, measurements were compared before and after surgery with a paired sample t test. To compare the 2 different surgical techniques, postoperative measurements were subtracted from preoperative measurements, and the differences determined for each group were compared with an independent t test. An adjusted comparison was performed via analysis of covariance (ANCOVA) with SPSS version 18 (SPSS, Inc, an IBM Company, Chicago, Illinois). Significance was defined as P <.05. REsuLts All 52 patients completed the study (26 in each group). There were no statistically significant differences between the study groups with respect to age (t = 1.618, P =.112) or sex (χ 2 = 0.746, P =.338). The mean (SD) age in the CT and HRCH groups was 22.8 (5.4) years and 25.5 (6.2) years, respectively. The CT group included 18 (69.2%) women, and the HRCH group included 15 (57.7%) women. The mean follow-up period was 15.7 months for the entire study population, 16.30 (range, 12-20) months for the CT group, and 15.19 (range, 12-20) months for the HRCH group. No patient experienced complications postoperatively. (Clinical photographs are shown in Figures 1 and 2.) First and second minimal cross-sectional areas (MCA1 and MCA2, respectively) increased after CT and HRCH. This increase was significant on the right side in both the CT (P <.001) and HRCH (P =.001) groups (Figure 3, Table 1). However, on the left side, the change was significant only in the HRCH group (P <.001; Figure 4, Table 1). As shown in Table 2, MCA1 of the left side increased by 6.27% and 37.08% in the CT and HRCH groups, respectively (P =.013). On the right side, MCA1 increased by 13.39% and 44.56% in the CT and HRCH groups, respectively (P =.028). MCA2 of the left side increased by 31.08% and 131.85% in the CT and HRCH groups, respectively (P <.005). On the right side, MCA2 increased by 77.76% and 115.11% in the CT and HRCH groups respectively; the difference was not statistically significant (P =.138). Based on preoperative and postoperative patient self-assessments with the VAS, both groups experienced decreased nasal obstruction following the surgery (Table 1). This decrease was not statistically significant between the 2 surgical methods for the left side (P =.336) or the right side (P =.831) (Table 2). discussion The results of this study indicated improvement in both subjective assessment of breathing quality and objective measurement of cross-sectional areas (especially on the left side) following tip-plasty in which a cephalic hinged flap of the LC was placed (Table 1). As suggested by our initial hypothesis, this technique may provide satisfactory clinical and aesthetic outcomes. The improvements noted in breathing quality and AR measurements suggest that hinged flaps may be effective in reconstructing the internal nasal valve (Figure 5). In the past 2 decades, clinical application of acoustic rhinometry (AR) has expanded. Clinically relevant studies are now available for septoplasty, turbinateplasty, sinus surgery, and facial cosmetic surgery. 20-23 AR provides an outline of the cross-sectional areas within the nose and the volume of the nasal cavity. The advantages associated with AR include time efficiency and the need for only minimal patient cooperation. Researchers have correlated a crosssectional area measured by computed tomography with a cross section measured by AR. 24 In addition, views obtained by magnetic resonance imaging (MRI) have been correlated with cross-sectional areas as measured by AR in the decongested nose. The hinged flap, first introduced in 2010, is believed to reduce nasal tip volume while maintaining support and strength in the nasal tip. 15,17 The preserved cephalic portion of the LC, when rotated and secured with sutures, provides additional tip support to the tripod. (The conjoined medial crura forms 1 leg of the tripod, and each of the lower lateral crus forms the other 2 legs.) In a crosssectional cadaveric study, Sazgar et al 19 showed that hinged flaps prevent posterior and caudal displacement of the LC s caudal portion. Applying a practical classification

690 Aesthetic Surgery Journal 34(5) Figure 1. (A, C) This 24-year-old man presented for rhinoplasty involving horizontal resection with cephalic hinged flap of the lateral crura. (B, D) The same patient, 14 months postoperatively. system for tip-plasty, Sazgar and Most 18 studied and discussed the aesthetic results of this particular technique. Separation of the ULC and LLC, and consequent destruction of the scroll area in combination with wide mucosal undermining, is a common technique of previously studied rhinoplasty approaches. 10-14 However, we did not apply these maneuvers in the hinged flap technique. Compared with other LLC flaps, such as turn-in, turn-out, and sliding flaps, the orientation and position of the hinged flap have differed in our hands. 19 There is evidence that the hinged flap effectively improves the airway. Data from our cross-sectional cadaveric study 19

Amali et al 691 Figure 2. (A, C) Preoperatively, this 29-year-old woman presented with a bulbous droopy tip for rhinoplasty involving horizontal resection with cephalic hinged flap of the lateral crura. (B, D) The same patient, 1 year postoperatively. indicated that the hinged flap prevents posterior and caudal displacement of the LC s caudal portion. The space beneath the alpha angle formed by the connection of the hinged flap and the caudal part of the LC of the LLC was added to the valve area on the hinged flap side (Figure 5). Our present study demonstrates that this new surgical intervention for management of the LC does not adversely affect nasal airway function. According to both subjective and objective measurements, nasal airway patency was improved postoperatively in both the CT and HRCH groups. The fact that the increase was not statistically significant on the CT group s left side may relate to the small sample size. The percentage of increase was larger in the HRCH group for both MCA1 and MCA2. However, the difference was not statistically significant on the right side for MCA2, which also may be attributable to the small sample size. Another reason for the

692 Aesthetic Surgery Journal 34(5) Figure 3. (A) Preoperative and (B) postoperative acoustic rhinometry graphs for the right nasal cavity of a 24-year-old man who underwent open rhinoplasty with cephalic trim of the lateral crura. First and second minimal cross-sectional areas (MCA1 and MCA2) are indicated. Different solid colors show 4 times of acoustic rhinometry examination, and the dotted line is the baseline exam of the device. Figure 4. (A) Preoperative and (B) postoperative acoustic rhinometry graphs for the left nasal cavity of a 29-year-old man who underwent open rhinoplasty with the horizontal resection with cephalic hinged flap technique. The minimal crosssectional area was noted at the second valley, the deepest valley on the graph, which corresponds with the internal nasal valve. Different solid colors show 4 times of acoustic rhinometry examination, and the dotted line is the baseline exam of the device.

Amali et al 693 Table 1. Preoperative and Postoperative Comparisons of MCA1, MCA2, and VAS Scores for the CT and HRCH Techniques CT (n = 26) HRCH (n = 26) Before After P Before After P MCA1 Left 0.784 (0.197) 0.807 (0.223).583 0.681 (0.186) 0.899 (0.255) <.001 Right 0.766 (0.129) 0.862 (0.156) <.001 0.760 (0.241) 0.983 (0.331) <.001 MCA2 Left 0.826 (0.455) 0.901 (0.373).274 0.696 (0.511) 1.143 (0.494) <.001 Right 0.916 (0.513) 1.314 (0.584).001 1.024 (0.745) 1.601 (0.724) <.001 VAS score for nasal obstruction Left 4.19 (3.35) 1.42 (1.77) <.001 3.81 (3.61) 1.00 (1.17) <.001 Right 3.12 (2.78) 0.92 (1.41) <.001 3.27 (3.13) 0.88 (1.53) <.001 Data are means (SD); P is calculated as the difference between pre- and postoperative (1 year) measurements by paired sample t test. VAS scores ranged from 0 to 10. CT, cephalic trim; HRCH, horizontal resection with cephalic hinged flap; MCA1, first minimal cross-sectional area; MCA2, second minimal cross-sectional area; VAS, visual analog scale. Table 2. Comparison of Surgical Results After the CT and HRCH Techniques MCA1 difference between the right and left sides might relate to septal deviations. It is noteworthy that bilateral ULC spreader grafts or flaps are routine procedures for all of our rhinoplasty patients. de Pochat et al 25 demonstrated that open-structure rhinoplasty with placed spreader grafts is effective in reconstructing the internal nasal valve, with significant improvement of a mean MCA on AR. Because all patients in the present study underwent this procedure, the statistical significance of the difference between the HRCH and CT groups may relate to the difference in the technique applied to the LLCs. CT (n = 26) HRCH (n = 26) Unadjusted P Adjusted P Difference, Mean (SD) Change, % Difference, Mean (SD) Change, % Left 0.023 (0.212) 6.27 0.218 (0.226) 37.08.002.013 Right 0.096 (0.118) 13.39 0.223 (0.260) 44.56.029.028 MCA2 Left 0.075 (0.341) 31.08 0.447 (0.530) 131.85.004.005 Right 0.398 (0.523) 77.76 0.578 (0.603) 115.11.257.138 VAS score for nasal obstruction a Left 2.77 (2.87) 2.81 (2.74).961.336 Right 2.19 (2.19) 2.38 (2.89).788.831 The unadjusted P represents the comparison of postoperative results of CT and HRCH techniques by the independent t test; the adjusted P represents the comparison of postoperative results of CT and HRCH techniques by analysis of covariance. CT, cephalic trim; HRCH, horizontal resection with cephalic hinged flap; MCA1, first minimal cross-sectional area; MCA2, second minimal cross-sectional area; VAS, visual analog scale. a Percentage of change was not calculated for VAS assessment because some patients selected 0 preoperatively (on a scale of 0 to 10). An obvious limitation of this clinical study is the small study population. Because our study was performed in an academic teaching hospital, finding patients who fit our specific inclusion criteria was a challenge. We believe that future studies with larger sample sizes may help to confirm the results of this study. As with all studies involving AR, concerns about intraobserver variability exist. We attempted to address this potential limitation by having a single otolaryngologist (A.A.), who was blinded to the patients study group assignments, perform all AR tests.

694 Aesthetic Surgery Journal 34(5) Figure 5. Schematic postoperative cross section of the nose, as viewed through the nasal valve area. Note the small crosssectional area and partial obstruction by cephalic trim on the right side. On the left side, a cephalic hinged flap of the lateral crura (LC) has been created. Note each side s position of the caudal part of the LC. Also shown are the nasal septum (S), upper lateral cartilage (ULC), caudal part of the LC, the hinged flap, the angle between the hinged flap and ULC, and the angle between the hinged flap and caudal part of the LC. (Illustration by Christine Gralapp, MA, CMI, chrisgralapp.com) conclusions Most postrhinoplasty tip abnormalities occur secondary to loss of tip support and to excessive LLC resection. Because the hinged flap procedure can be performed in individuals who have weak cartilage and wide LC, such complications may be avoided. The hinged flap is an option in nasal tip reduction surgery that may improve long-term aesthetic and functional outcomes through NVA preservation. Future studies with longer follow-up periods and larger sample sizes are warranted to further elucidate the effectiveness of this technique as a replacement for LLC CT. Acknowledgment The authors thank Dr Sam P. Most, Professor of Otolaryngology Head and Neck Surgery at Stanford University Medical Center, Stanford, California, for sharing his opinions and clinical experiences. disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFEREncEs 1. Kim DW, Rodriguez-Bruno K. Functional rhinoplasty. Facial Plast Surg Clin North Am. 2009;17:115-131. 2. Tardy ME Jr, Thomas RJ. Rhinoplasty, surgical philosophy. In: Cummings CW, ed. Otolaryngology Head and Neck Surgery. Pennsylvania, PA: Mosby; 2010:508-509. 3. Yoo S, Most SP. Nasal airway preservation using the autospreader technique: analysis of outcomes using a diseasespecific quality-of-life instrument. Arch Facial Plast Surg. 2011;13:231-233. 4. Most SP. Analysis of outcomes after functional rhinoplasty using a disease-specific quality of life instrument. Arch Facial Plast Surg. 2006;8:306-309. 5. Constantlan MB. Valvular incompetence is most likely cause of postrhinoplasty airway problems. Aesthetic Surg J. 1998;18:58-60. 6. Fischer H, Gubisch W. Nasal valves: importance and surgical procedures. Facial Plast Surg. 2006;22:266-280. 7. Spielmann PM, White PS, Hussain SS. Surgical techniques for the treatment of nasal valve collapse: a systematic review. Laryngoscope. 2009;119:1281-1290. 8. Christophel JJ, Park SS. Complications in rhinoplasty. Facial Plast Surg Clin North Am. 2009;17:145-156. 9. Ballert JA, Park SS. Functional rhinoplasty: treatment of the dysfunctional nasal sidewall. Facial Plast Surg. 2006;22:49-54. 10. Massiha H. Elliptical horizontal excision and repair of alar cartilage in open-approach rhinoplasty to correct cartilaginous tip deformities. Plast Reconstr Surg. 1998;101:177-182.

Amali et al 695 11. Regalado-Briz A. Aesthetic rhinoplasty with maximum preservation of alar cartilages: experience with 52 consecutive cases. Plast Reconstr Surg. 1999;103:671-680. 12. Janis J, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter JP. Lower lateral crural turnover flap in open rhinoplasty. Plast Reconstr Surg. 2009;123:1830-1841. 13. Murakami CS, Barrera JE, Most SP. Preserving structural integrity of the alar cartilage in aesthetic rhinoplasty using a cephalic turn-in flap. Arch Facial Plast Surg. 2009;11:126-128. 14. Ozmen S, Eryilmaz T, Sencan A, et al. Sliding alar cartilage (SAC): a new technique for nasal tip surgery. Ann Surg. 2009;63:480-485. 15. Sazgar AA. Horizontal reduction using a cephalic hinged flap of the lateral crura: a method to treat the bulbous nasal tip. Aesthetic Plast Surg. 2010;34:642-645. 16. Gruber RP, Zang A, Mohebali K. Preventing alar retraction by preservation of the lateral crus. Plast Reconstr Surg. 2010;126:581-588. 17. Sazgar AA. Lateral crural setback with cephalic turn-in flap: a method to treat the drooping nose. Arch Facial Plast Surg. 2010;12:427-430. 18. Sazgar AA, Most SP. Stabilization of nasal tip support in nasal tip reduction surgery. Otolaryngol Head Neck Surg. 2011;145:932-934. 19. Sazgar AA, Woodard C, Most SP. Preservation of the nasal valve area with a lateral crural hinged flap: a cadaveric study. Aesthetic Plast Surg. 2012;36:244-247. 20. Skouras A, Noussios G, Chouridis P, Argyriou N, Kontzoglou G. Acoustic rhinometry to evaluate plastic surgery results of the nasal septum. B-ENT. 2009;5:19-23. 21. Kemker B, Liu X, Gungor A, Moinuddin R, Corey JP. Effect of nasal surgery on the nasal cavity as determined by acoustic rhinometry. Otolaryngol Head Neck Surg. 1999;121:567-571. 22. Grymer LF. Reduction rhinoplasty and nasal patency: change in the cross-sectional area of the nose evaluated by acoustic rhinometry. Laryngoscope. 1995;105:429-431. 23. Hormozi AK, Toosi AB. Rhinometry: an important clinical index for evaluation of the nose before and after rhinoplasty. Aesthetic Plast Surg. 2008;32:286-293. 24. Terheyden H, Maune S, Mertens J, Hilberg O. Acoustic rhinometry: validation by three-dimensionally reconstructed computer tomographic scans. J Appl Physiol. 2000;89:1013-1021. 25. de Pochat VD, Alonso N, Mendes RR, Cunha MS, Menezes JV. Nasal patency after open rhinoplasty with spreader grafts. J Plast Reconstr Aesthetic Surg. 2012;65:732-738.