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Original Investigation |

Newly Designed Upper Lateral Cartilage Flap for Preventing Depression of the Keystone Area in Large-Nose Septorhinoplasty

Maryam Sharafi, MD1,2; Maryam Jalessi, MD3; Peter A. Adamson, MD, FRCSC, FACS4
[+] Author Affiliations
1Otolaryngology Department, Golsar Hospital, Rasht, Iran
2Otolaryngology Department, Arya Hospital, Rasht, Iran
3Ear, Nose, Throat–Head and Neck Research Center and Department, Hazrat Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
4Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
JAMA Facial Plast Surg. 2015;17(6):399-404. doi:10.1001/jamafacial.2015.0904.
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Importance  Because large dorsal reduction may weaken the keystone area, later notching of this area should be prevented while reducing large humps during septorhinoplasty.

Objective  To determine whether a triangular-shaped flap of upper lateral cartilages (ULCs) that we designed can prevent secondary deformity of the nasal dorsum in the keystone area following large hump reduction.

Design, Setting, and Participants  In this retrospective study, medical records as well as preoperative and postoperative photographs of septorhinoplasty cases in which triangular flaps had been used between April 1, 2012, and March 3, 2013, were reviewed. Data analysis was conducted from March 3 to May 10, 2014. Demographic data, amount of hump reduction, and any irregularity of the dorsum in the keystone area mentioned in the medical record or identified in postoperative profile view photographs were assessed. The study was conducted in a research center, and the operations were performed in a private setting. Patients had been scheduled for septorhinoplasty with flap reconstruction if more than 3 mm of dorsal hump reduction was planned and their skin was not thin. Of 41 identified patients, 3 could not be monitored for 1 year; 38 patients were included in the analysis.

Exposures  Open septorhinoplasty had been performed, and more than 3 mm of dorsum had been removed in all patients whose data were analyzed. During stepwise resection of the nasal dorsum, a triangular-shaped remnant of the most cephalomedial part of the ULC was maintained intact on each side over the keystone area.

Main Outcomes and Measures  Irregularity of the nasal dorsum over the keystone area in postoperative profile view photographs.

Results  More than 3 mm of hump reduction had been made in all 38 patients. No irregularities were observed in the postoperative photographs or had been found on digital examination of the keystone area after at least 12 months of follow-up.

Conclusion and Relevance  Maintaining a remnant of the ULC over the keystone area in the form of a triangular-shaped flap on each side is a simple, reliable, and durable way to prevent notching of the keystone area during lowering of the nasal dorsum in large noses with sufficient skin thickness.

Level of Evidence  4.

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Figure 1.
Triangular-Shaped Cartilage Flap (TF)

A, The upper lateral cartilages (ULCs) are being trimmed by curved iris scissors. B, This trimming leaves a TF in the cephalomedial part of the ULCs in the keystone area. These cartilaginous remnants act as 2 flaps that cover the area where the cartilaginous dorsal septum integrates with the ULCs and nasal bones after medial and lateral osteotomies were performed. SG indicates spreader graft.

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Figure 2.
Preoperative and Postoperative Photographs of Patients Who Received Triangular Flaps of Upper Lateral Cartilages

There is no bulging or notching of the keystone area in the profile views.

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Figure 3.
The Cartilaginous Dome Beneath the Bony Dome

The photograph, taken after removal of the bony hump, shows the cartilaginous dome underneath.

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Figure 4.
The Triangular Flap in a Patient With Thin Skin

The remaining triangular-shaped parts of the upper lateral cartilage (ULC) may be seen as a very slight bulging (arrowhead) at the keystone area at the end of the operation (before placement of the tape) in a patient with thin skin. This bulging is due to ULC resistance. However, on palpation, no ridge or bump should be noted; there should only be a fullness of the keystone area that is aligned with the bony and cartilaginous dorsum. Preserving the most cephalomedial part of the ULCs as 2 triangular flaps reaching the midline when more than 3 mm of hump is removed from a patient with normal skin can prevent keystone area notching by restoring the cartilaginous dome under the skin of this area.

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