18th International Course in Modern Rhinoplasty Techniques & Symposium The Cleft Lip Patient and Revision surgery 26, 27 & 28 October 2011 http://www.rhinoplastycourse.nl/​

1. Grafts in Nasal Surgery D.J. Menger Academic Medical Center Amsterdam The Netherlands

2. Columellar strut preferred cartilage graft: septal, auricular, costal or irradiated rib. DJ Menger

3. A columellar strut stabilizes the medial crura of the lower lateral cartilages. They can be used to straighten and strengthen the columella. In this patient in combination with a hump reduction, tip refinement and upward rotation of the drooping tip. DJ Menger

4. Shield graft preferred cartilage graft: auricular or septal. Second choice: costal DJ Menger

5. A shield graft is positioned anterior to the medial crura above the dome area. It brings the overlying skin tissue in a higher position which gives the illusion of more nasal tip projection. The shield can camouflage asymmetries of the tip and it can lengthen the short nose. DJ Menger

6. This patient had a cleft lip on the left side including all the characteristics of the cleft lip nose; a strong septal deviation, flattening of the left ala and lack of nasal tip projection. DJ Menger

7. Spreader graft preferred grafts: septal, auricular, costal or irradiated rib. DJ Menger

8. A spreader graft is placed between the nasal septum and the upper lateral cartilages. The effect is fourfold: widening the internal nasal valve angle, camouflage of concavities in the mid mid nasal third, prevention of the inverted V syndrome and lengthening of the short nose. DJ Menger

9. This patient had breathing problems and a concavity of the mid nasal third on the right side. One graft was used, a spreader graft in combination with a hump reduction and tip suture techniques. DJ Menger

10. Dorsal onlay and septal replacement graft preferred cartilage grafts: septal, auricular, costal or irradiated rib DJ Menger

11. A dorsal onlay graft can be used to camouflage irregularities- or a saddle of the nasal dorsum. The edges could be beveled securely in order to avoid the graft to be visible through the overlying skin. DJ Menger

12. This patient had previous septal surgery elsewhere and developed a septal abscess postoperatively. The caudal septum was reconstructed with auricular cartilage in combination with a limited hump removal and a small dorsal onlay graft. DJ Menger

13. Dorsal onlay graft and septal correction DJ Menger

14. A deviation of the caudal part of the nasal septum can be straightened with scoring, always in combination with splinting of this area with a strong- and straight piece of cartilage graft. Fixation in the midline to the anterior nasal spine. DJ Menger

15. This patient had nasal trauma and developed a saddle nose deformity. Reconstruction was performed using a dorsal onlay graft in combination with a limited hump reduction, osteotomies and a septal correction. DJ Menger

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18. Dorsal augmentation and tip refinement DJ Menger

19. This patient had a previous rhinoplasty elsewhere. Her nasal dorsum was too low and not in harmony with the rest of her face, especially with her strong mandible. She had bifidity and hanging nasal tip defining points, this was refined and balanced using tip suture techniques. DJ Menger

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22. Reallocation of the lateral crura DJ Menger

23. This patient had breathing problems due to concavities of the lateral crura of the lower lateral cartilages, which protruded into the nasal vestibule. This concave configuration can be altered by complete dissection of the lateral crura in order to turn them around. DJ Menger

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25. Osteotomies, spreader grafts, reallocation of the lateral crura, septal correction, columellar strut and tip suture techniques. DJ Menger

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27. Augmentation of the frontonasal angle preferred materials: septal, auricular, costal, irradiated costal grafts DJ Menger

28. This patient had a pseudo over-projection of the nasal tip due to an unbalanced nose in which the naso-frontal angle was too deep. Only the radix was augmented using auricular cartilage through an endonasal approach. DJ Menger

29. This patient had over-resection of the bony nasal dorsum after a rhinoplasty performed elsewhere. Augmentation was performed using septal cartilage. DJ Menger

30. Alar retraction, rim reconstruction preferred material: composite graft, auricular cartilage DJ Menger

31. This patient had a hump deformation, a crowded upper-lip and mild retraction of the alar rim. DJ Menger

32. A rhinoplasty was performed including a hump reduction, osteotomies, spreader grafts, reduction of the anterior nasal spine, a columellar strut, tip sutures and a small composite graft. This graft was positioned alongside the caudal rim of the lateral crura in order to lower the alar rim. DJ Menger

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34. alar rim graft preferred materials: septal, auricular, costal, irradiated costal grafts DJ Menger

35. An alar rim graft can stabilize the alar rim, especially the soft triangle of Converse. DJ Menger

36. Create a small pocked in the alar rim and introduce the graft. DJ Menger

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38. Fixation of the graft can be carried out with the use of a soluble suture through-and-through all layers. DJ Menger

39. When the suture is reintroduced exactly at the same site where it came out (but in an other angle), you can pull the suture through the cutis and fixate the graft. DJ Menger

40. Slight augmentation of the fronto-nasal angle, reduction of the cartilaginous dorsum, columellar strut, a shield graft and alar rim grafts. DJ Menger

41. vestibular stenosis, auricular composite graft DJ Menger

42. This patient had a cleft lip on the left side and an iatrogenic pinpoint-stenosis of the left vestibule due to intubation in childhood. Stenosis of the vestibule was treated using an auricular composite graft in order to restore the shortage of inner lining. DJ Menger

43. The donor area can be closed with a free skin flap that can be harvested retro-auricular. This area can be closed primarily. DJ Menger

44. The composite graft was sutured in place in the nasal vestibule. DJ Menger

45. before-, during- and one year after surgery DJ Menger

46. In the postoperative period of vestibular stenosis and cleft lip surgery, a custom made vestibular device can be used to reduce the chance of re-stenosis. (6 weeks day and night and than for a period of 6 weeks only during the night) DJ Menger Postoperative management of nasal vestibular stenosis: the custom-made vestibular device. Menger DJ, Lohuis PJ, Kerssemakers S, Nolst Trenité GJ. Arch Facial Plast Surg. 2005 Nov-Dec;7(6):381-6.

47. Total septal replacement in children after nasal septal abscess preferred material: auricular or costal cartilage DJ Menger

48. This girl had a nasal septal abscess after trauma. Her entire septal cartilage was destructed. Without reconstruction she would develop a saddle nose deformity with too much upward rotation of the nasal tip and underdevelopment of both the nose and the mid-face. DJ Menger

49. Reconstruction was performed using auricular cartilage fixed to PDS plate. PDS acts as a carrier and stabilizes the different pieces of cartilage into one large implant. This implant precisely fits between the perpendicular plate, the upper lateral cartilages and the premaxilla. Fixation to the nasal spine and UL. DJ Menger Nasal septal abscess in children: reconstruction with autologous cartilage grafts on polydioxanone plate. Menger DJ, Tabink IC, Trenité GJ. Arch Otolaryngol Head Neck Surg. 2008 Aug;134(8):842-7.

50. before and 2 years after surgery DJ Menger

51. Autologous cartilage from the rib or auricle is the first choice for the reconstruction of the nasal septum in a growing child. DJ Menger Treatment of septal hematomas and abscesses in children. Menger DJ, Tabink I, Nolst Trenité GJ. Facial Plast Surg. 2007 Nov;23(4):239-43.

52. A boy who developed a septal abscess after nasal trauma. There were still signs of abscess formation in the septum at the time of presentation, two weeks after the trauma. DJ Menger

53. In this case costal cartilage was used. Slices of 1 mm were fixated to PDS foil and placed back between the mucoperichondrium blades. DJ Menger Nasal septal abscess in children: reconstruction with autologous cartilage grafts on polydioxanone plate. Menger DJ, Tabink IC, Trenité GJ. Arch Otolaryngol Head Neck Surg. 2008 Aug;134(8):842-7.

54. pre- and postoperative DJ Menger

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56. Total septal reconstruction in adults DJ Menger

57. In adults, not the entire septum has to be reconstructed because there is no chance of underdevelopment. A dorsal splint attached to a caudal splint is sufficient to prevent a saddle deformity and retraction of the columella respectively. DJ Menger

58. In this case irradiated rib grafts were used. These grafts are safe to use and provide a stable long term postoperative result. The grafts were fixated to PDS plate, behind the caudal splint a remnant of septal cartilage was crushed and placed on the foil to avoid the chance of a septal perforation. DJ Menger

59. The septal replacement graft was positioned between the mucosal layers and fixed to anterior nasal spine and the bony pyramid. DJ Menger Irradiated homologous rib grafts in nasal reconstruction. Menger DJ, Nolst Trenité GJ. Arch Facial Plast Surg. 2010 Mar-Apr;12(2):114-8.

60. A small hole was drilled in the nasal bone in order to suture the dorsal splint to the bony part. DJ Menger Irradiated homologous rib grafts in nasal reconstruction. Menger DJ, Nolst Trenité GJ. Arch Facial Plast Surg. 2010 Mar-Apr;12(2):114-8.

61. Total dorsal augmentation: “Leprosy Technique” preferred materials: auricular, septal, costal or irradiated rib. DJ Menger Reconstructive surgery of the leprosy nose: a new approach. Menger DJ, Fokkens WJ, Lohuis PJ, Ingels KJ, Nolst Trenité GJ. J Plast Reconstr Aesthet Surg. 2007;60(2):152-62. Epub 2006 Sep 14.

62. This patient had complete lack of her bony dorsum. Reconstruction was performed using a costal cartilage dorsal onlay graft attached to a columellar stut. DJ Menger Reconstructive surgery of the leprosy nose: a new approach. Menger DJ, Fokkens WJ, Lohuis PJ, Ingels KJ, Nolst Trenité GJ. J Plast Reconstr Aesthet Surg. 2007;60(2):152-62. Epub 2006 Sep 14 .

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64. side-wall graft preferred materials: auricular, septal, costal or irradiated rib. DJ Menger

65. A sidewall graft can be used to camouflage concavities or irregularities of the nasal sidewall. This patient had previous surgery elsewhere with over-resection of the bony pyramid, the upper- and lower lateral cartilages. DJ Menger

66. Reconstruction was performed using a dorsal onlay graft, side wall grafts and replacement of the lower lateral cartilages. DJ Menger

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68. Alar batten preferred materials: auricular, septal, costal or irradiated rib DJ Menger

69. Alar battens can be used to stabilize the lateral wall of the internal- and external nasal valve. They can also be used to change the contour of the ala, for example in cleft-lip patients. DJ Menger

70. A “ guiding suture” can be helpful to position the batten in a pocket . DJ Menger

71. To widen the external nasal valve, the battens should be pushed down as much as possible, while the lateral crus is pulled up during fixation of the batten to the crus. DJ Menger

72. This patient had a unilateral cleft-lip on the left side with the typical flattening of the ala. DJ Menger

73. An alar batten graft on the left side was used to bring the lateral crus in a more symmetric position. The floor of the nose was augmented using cartilage grafts. DJ Menger

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75. This patient had breathing problems on the left side due to a caudal septal deviation and a concavity of the lateral crus of the lower lateral cartilage on the lefts side. DJ Menger

76. In this case not an alar batten but a lateral crus extension graft was used to alter the configuration of the crus. The extension graft should be placed into a pocked that is relatively too small, this will push-up the lower lateral. DJ Menger

77. An alternative for alar battens is “the lateral crus pull-up”. It is a suture technique in which the lateral crus is pulled up laterally and upward to the bony pyramid. The effect is twofold; widening of the valve area and strengthening of the lateral wall. DJ Menger Lateral crus pull-up: a method for collapse of the external nasal valve. Menger DJ. Arch Facial Plast Surg. 2006 Sep-Oct;8(5):333-7.

78. Lateral crus pull-up: surgical steps DJ Menger Lateral crus pull-up: a method for collapse of the external nasal valve. Menger DJ. Arch Facial Plast Surg. 2006 Sep-Oct;8(5):333-7.

79. Lateral crus pull-up: surgical steps DJ Menger Lateral crus pull-up: a method for collapse of the external nasal valve. Menger DJ. Arch Facial Plast Surg. 2006 Sep-Oct;8(5):333-7.

80. This patient had multiple rhinoplasties and other surgical procedures performed abroad. She had irregularities of the nasal dorsum, severe columellar retraction, no tip projection and fibrosis and scars of the overlying soft tissue envelope. DJ Menger

81. There were no original structures of the nasal skeleton left. All nasal grafts were removed and rebuild, only the overlying envelope was preserved. DJ Menger

82. Recontruction was performed using rib grafts, auricular cartilage and composite grafts. A dorsal onlay graft was attached to a columellar strut, sidewall grafts, a shield graft, lateral crus replacement grafts and composite grafts to restore the inner lining of the nasal vestibule. DJ Menger

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