Introduction
Rhinoplasty surgery forms a vital part of the functional and aesthetic management of congenital or traumatic deformities of the facial skeleton. This chapter will cover important aspects of
· nasal anatomy,
· assessment of the deformity,
· surgical planning, and
· operative procedures.
It is essential that the reader refers to a comprehensive or specialist texts for detailed aspects of the surgery.
The nose is a complex structure cantilevered on the mid face. Its complex role embraces the senses of smell and taste, respiration, aesthetics and sex and so rhinoplasty surgery requires careful consideration. All mid face orthognathic surgery will affect the nose to a degree. LeFort I operation impactions broaden the alar width, and with inadequate trimming of the nasal septum they will lead to septal buckling and obstruction or deviation of the nasal tip. Advancements will raise the nasal tip and straighten out profile curvatures. For these reasons it is undesirable to do a rhinoplasty before, during or within 6 months of a mid face osteotomy.
Anatomy
It is important to understand the complex nasal anatomy which is made difficult by the nomenclature. The upper border of many structures is designated cephalic (headwise) and the lower border caudal (tailwise). The anterior surface of the nose is dorsal and posterior structures are posterior. Unfotunately some terms have been introduced in relation to the supine anaesthetised patient, so that what might be considered as anterior and posterior nasal sites are described as “high” and “low”.
Figures 12.1 and 12.2 show the anatomical subunits of the nose, which is conveniently divided in thirds. The upper third consists of the bony pyramid, made up of the nasal bones with their articulation to the ascending processes of the maxilla and the bony septum. The paired upper lateral cartilages insert just under the caudal (lower) end of the nasal bones and their fusion with the midline cartilaginous septum in a “T” type configuration forms the middle third (“vault”) (Figure 12.2). The attachment of the caudal aspect of the upper lateral Cephalic cartilage to the cephalic (upper) aspect of lower lateral cartilages forms the boundary to the lower third of the nose and is referred to as the scroll attachment. The paired lower laterals, sometimes called the alar cartilages, form the a prominent part of the lateral surface of many noses and the nasal tip, They are divided into the lateral, intermediate and medial crurae — or processes (Figures 12.3a and 12.3b). The intermediate crurae form the “domes” and are the tip defining points of the nose.
Figure 12.1 External anatomy of nose (lateral view).
Figure 12.2 External anatomy of nose (frontal view).
The medial crura curve medially and backwards and their terminal processes, the so-called footplates abut against the border of the caudal aspect of the nasal septum and form the cartilaginous columella.
The columella with its cartilage and skin provide the external (caudal) border of the septum from the tip to the nasolabial angle. The outer margin of the nares are the soft tissue alar lobules that are devoid of cartilage.
The overlying superficial musculoaponeurotic system (SMAS) of the nose is a complex layer which provides a rich vascular supply covering to the underlying skeleton and is derived from the superior labial and facial arteries and corresponding venous and lymphatic vessels accompanying these. Its intrinsic aponeurotic muscles have elevator, depressor, compressor and dilator functions which contribute to olfaction and facial expression.
Figure 12.3 (a) and (b) Lower lateral cartilage anatomy.
The external anatomy of the nose is readily studied in any crowded place.
Assessment
History
A detailed history covering the functional and aesthetic aspects of the nose is mandatory.
To assess function, the patient is asked specifically regarding the presence and duration of nasal obstruction, sinus disease and allergic type symptoms. It is important to document prior medical and surgical treatments and their efficacy in treating any functional or aesthetic complaints.
A detailed history of traumatic injuries to the nose and surrounding facial skeleton is essential especially if operated on, and an indication of the pretraumatic appearance of the nose is helpful. It is particularly important to gauge the patient's specific concerns about the appearance of each subsection of the nose with direct questioning. A generalised vague reference to a dislike of the overall look of the nose or any suggestion that the surgeon should decide where the problems lie is to be discouraged and may be suggestive of a dysmorphic disorder (see Chapter 6). The patient's thoughts about the overall improvement desired are sought and realistic expectations estimated. A general medical history should screen the patient for bleeding disorders, cardiovascular and respiratory disease and importantly a psychiatric history.
Examination
A detailed examination of the internal and external aspects of the nose is performed. Anterior rhinoscopy to detail mucosal, caudal septal and turbinate deformities is supplemented with an endoscopic evaluation of the posterior nasal cavity and middle meatal areas to exclude infective or obstructive sinonasal disease. The internal nasal valve area which is bounded by the upper lateral cartilage, inferior turbinate, nasal septum and nasal floor is specifically examined and any high septal deformity noted. This is the narrowest part of the nasal airway and significant internal nasal valve collapse can be demonstrated by Cottle's test (Figure 12.4) in which the airway improves when the cheek adjacent to the mid third of the nose, i.e. the upper lateral cartilage is pulled laterally.
Figure 12.4 Demonstration of Cottle's test.
The importance of the balance of the nose to other aspects of the face is important. Assessment of this relationship should form the initial part of the external examination process. The patient's ethnic characteristics must also be considered. Facial and nasal asymmetries are documented and detailed to the patient.
The skin-soft tissue envelope is important and is critical in predicting postoperative changes. Thinner skin may show minor postoperative irregularities whilst very thick skin can hide any corrections made.
An initial evaluation of the underlying skeletal aspects of the nose considers three fundamental parameters: length (nasion to tip), projection of the dorsum and rotation of the nasal tip. Detailed examination should then document deformities in relation to these factors.
External deformity is most easily assessed and documented in nasal thirds. The frontal, lateral, oblique and basal views (Figures 12.5a–12.5g) are all separately visualised.
Figure 12.5 (a)–(g) Standard photography views.
· The upper bony pyramid is examined for deviation, irregularity and the extent of any dorsal hump. The width of the base of the dorsal pyramid is determined and the dorsum palpated to ensure there is no “open roof” type deformity.
· Similar deformities are sought in the mid third of the nose which is cartilaginous. In this area, an assessment of any externally visible collapse in the nasal valve area is made by inspection and Cottle's test.
· The lower third nasal tip region, which is made up of the lower lateral cartilages is assessed for asymmetry, bulbosity, projection and rotation. A judgement regarding the width of the alar base in relation to the facial proportions is made. The alar width should match the normal intercanthal distance.
Documentation
Documentation of all aspects of the examination is critical for clinical and medicolegal purposes. A rhinoplasty assessment form can be very useful in this regard. It ensures all the areas of the evaluation are considered methodically and can be used for standardising the assessment for all patients.
The patient's expectations and all discussion points are clearly noted. A surgical plan is formulated to correct the specific deformities. It is essential to ensure the patient is given realistic expectations for the outcome of intended surgery, and limitations together with potential complications are discussed. It is very important to ensure that improvement is indeed likely and a risk benefit profile needs to be detailed to the patient prior to obtaining consent and carefully noted.
The surgical approach, be it endonasal or external, should be discussed with the patient and incisions outlined and documented.
Photography and Computer Imaging
Preoperative photography is an absolute requirement for analysis and medicolegal purposes. Standard view photographs form a useful way of communicating deformities and potential changes to the patient. They assist in operative planning and are invaluable for reference during surgery. In combination with postoperative images, they allow self- and peer-reviewed assessment of results.
Standardisation is critical both from the views taken and lighting and background conditions. Digital SLR photography has now largely taken over from 35 mm film and the new technology lends itself well to computer archiving and digital imaging. A standard neutral background such a pale grey, or green or blue is used and ideally a soft exposure is achieved using a flash unit and umbrellas placed equidistant from the patient and camera. The camera should be two metres from the subject and an appropriate zoom used to compose the image using the portrait outline. An overhead lamp, a “kicker” above the patients head can help eliminate unwanted shadows (Figure 12.6).
Figure 12.6 Photography setup.
The standard views are as follows (Figures 12.5a–12.5g):
1. Straight frontal view. The patient looks directly into the camera with the eyeline in a horizontal plane.
2. Lateral view. The patients Frankfort plane should be horizontal. This view assesses dorsal profile and is critical in assessing the three basic parameters of length, projection and rotation of the nose. The nose-chin relationship is also clearly demonstrated. A separate lateral view with the patient smiling may outline dynamic movement in the nasal tip.
3. Oblique views. These views are at taken at 45 degrees to the frontal views and can outline asymmetries and contours.
4. Basal view. This view is taken looking up the nose and focuses on the nasal tip detailing asymmetry and deformity.
5. “Birds eye” view. This view is taken from the top of the patient looking down the nose. It can be useful in showing the subtleties of deviation of the nose.
Digital imaging has evolved greatly over the past few years and simple morphing is possible with inexpensive photo-imaging software. More complex programmes are, readily available with or without archiving capability and have purpose made user interfaces and more advanced digital manipulation of the images. With rhinoplasty surgery, they can be very useful in showing patients potential changes and postoperative outcomes. This is most useful in detailing profile changes in the lateral view but with some experience frontal views can be morphed to show potential width reduction and refinement in the nasal tip. Dedicated programmes have measurement abilities and so can be extremely helpful in operative planning. It is important not to convey unrealistic changes to the patient — this will be a source of dissatisfaction afterwards. As a rule a slight underestimation of the postoperative result is generally favourable. Most surgeons choose not to give printed images to the patient of the predicted changes but if you do so, a printed waiver should make clear that the image is only an indication of the likely result.
Surgical Approaches
As a general rule, it is best to limit surgical tissue dissection to a minimum to reduce the risk of vascular compromise of the skin-soft tissue envelope. In this way, additional scarring is prevented and healing is more predictable. Limited dissection also makes it easier to judge the underlying structural components and position of placed underlying grafts.
There are two basic approaches to the nasal skeleton:
i) the endonasal or closed approach and
ii) the external or open approach.
The advantages and disadvantages of each are much debated and many authors advocate one method to the exclusion of the other. Each offers benefits in specific situations and should be within the repertoire of a rhinoplasty surgeon.
The least traumatic method of dissection to achieve the specific goal should be used and as such the endonasal approach is favoured for all simple cases unless a better result using the open technique.
Endonasal Approach
The endonasal approach only requires incisions within the nose with no visible external scars (Figures 12.8–12.10). Minimal soft tissue dissection is needed, making this method favourable for less marked deformities and is ideal for correcting bony dorsal irregularities. Its benefits lie in the limited soft tissue disruption allowing early and predictable healing due to the comparatively reduced scar tissue formation. Its main limitations are the restricted exposure of the underlying nasal skeletal elements. The endonasal approach can further be divided into delivery and non-delivery approaches dependent on whether the lower lateral cartilages are fully delivered. With delivery the cartilage is exposed and withdrawn from its overlying subcutaneous layer. The incisions required for these are detailed later.
External Approach
The external approach requires a mid-columellar skin incision which is joined to bilateral marginal incisions (Figure 12.11). More soft tissue dissection is required but provides an unparalleled view of the nasal structures, facilitating diagnosis and correction by bimanual tissue handling. Other benefits include binocular vision for the surgeon, control of bleeding with diathermy, precise placement and suturing of struts, battens, shield and spreader grafts. This approach also offers a definite teaching advantage although this should not be thought of as an indication for its use. The external approach is favoured for most major reconstructive rhinoplasty and revision surgery, particularly where the nasal tip needs addressing. Recent incision refinements and surgical technique have overcome some of the earlier criticisms of a columellar scar, delay in resolution of the supratip skin oedema, loss of tip projection and extra operating time. However with this approach, it may be difficult to assess the supra-tip area and the desired tip projection due to the lack of traction of the soft tissue prior to closure of the columella incision. Specific indications for the external approach in rhinoplasty include:
· congenital deformities such as the “cleft lip nose”,
· extensive revision surgery,
· severe nasal trauma,
· the markedly deviated nose,
· marked tip deformities, and
· situations where assessment of the exact pathology is difficult.
Extended applications of the external approach enable greater exploitation of the nasal skeleton and the advantages this affords. It has been advocated for nasoseptal perforation repair, access to the nasal dorsum for treatment of nasal dermoids and even as an approach to hypophysectomy.
Operative Techniques
Anaesthesia
Rhinoplasty surgery is usually performed under general anaesthesia although local anaesthetic and sedation are also possible. The face is prepared with an aqueous detergent and draped to reveal the eyes, the corneas are simply protected with lacrilube ointment. The intranasal mucosal cavity is prepared preoperatively with a (10%) cocaine vasoconstrictor solution. Local anaesthesia with a vasoconstrictor is then injected to further minimise intraoperative bleeding. A dental syringe and needle are used with a 2% lidocaine and 1:80,000 adrenaline cartridge. The injection sites are as follows (Figures 12.7a–12.7d):
Figure 12.7 (a)-(d) Local infiltration technique for rhinoplasty.
a) along lateral wall of nose through intercartilaginous area,
b) base of the columella and collumellar region if the external approach is used,
c) vestibular and non-vestibular aspects of the lower lateral cartilages (the alar cartilages),
d) caudal septal cartilage area, and
e) alar bases if reduction planned (not shown).
Injection over the immediate dorsum is best avoided as the resultant swelling can make assessment of this area difficult. Lateral nose depot injections can be massaged upwards into the dorsal area to reduce bleeding when the skin-soft tissue envelope is being elevated. Leaving adequate time for the anaesthesia to take effect is critical in exploiting its haemostatic advantage.
Incisions
Elevation of the skin and soft tissue envelope is facilitated by various incisions.
1. Intercartilaginous
The intercartilaginous incision (Figures 12.8a–12.8c) is the most commonly used in endonasal rhinoplasty. It allows direct access to the mid and upper thirds of the nose but affords no exposure of the tip cartilages. It is often used in combination with other incisions if tip surgery needs to be performed.
The incision is made in the area separating the upper and lower lateral cartilages. A small linear hollow is seen intranasally demarcating the area between the caudal border of the upper lateral and the cephalic border of the lower lateral cartilages. It is usually seen and easily palpable when the alar margin is retracted upwards and everted using a two-pronged skin hook (Figure 12.8a).
· An incision is made into this hollow laterally (Figure 12.8b) and the blade is then turned forwards and medially along the intercartilaginous junction and onto the caudal septum to make a transfixion incision below the caudal cartilaginous septum, i.e. the incision passes through the membranous septum between the medial crura and the caudal septum.
· It is important to ensure this transfixion incision does not extend more than half way along the columella as further extension risks dividing the medial crural attachment to the caudal septum. This is one of the major tip support mechanisms, and division may result in postoperative tip ptosis. Conversely, an extended full transfixion incision can be utilised as a manoeuvre for deprojection of the tip if required.
· With retraction of the lower lateral cartilage, the overlying skin-soft tissue envelope can be gently elevated off the cartilaginous dorsum of the upper lateral cartilages by sharp dissection upwards using a sawing motion with a No. 15 blade in a supraperichondral plane (Figure 12.8c).
Figure 12.8 (a)-(c) Intercartilaginous incision technique.
· After the cartilaginous vault is freed of overlying tissue, an incision is made into the caudal end of the periosteum of the nasal bony pyramid.
· The periosteum and its overlying procerus muscle can then be elevated using the side of a Joseph elevator. Such elevation needs extend only far enough laterally to gain access to a dorsal hump.
· The intercartilaginous incision approach does not expose the lower lateral cartilages although retrograde exposure of the cephalic border may allow volume reduction of this area.
Whilst these incisions are mucosal and as such should heal very well, it is the author's preference to close these with fast absorbing sutures (4.0 Vicryl Rapide — Ethicon).
2. Cartilage Splitting (Intracartilaginous, Transcartilaginous)
The cartilage splitting incision facilitates volume reduction of the cephalic border of the lower lateral cartilages. It is frequently performed in addition to reduction of the dorsum.
· The cephalic border of the lower lateral cartilage is identified in the vestibular region and a length of at least 8 mm of cartilage is marked to be left as an intact strip.
· An incision is then made through the vestibular skin which is then freed from the lower lateral cartilage (Figure 12.9a).
· The cephalic edge of the cartilage requiring excision is exposed and incised at the appropriate level as determined by the amount of cartilage to be removed.
· The incised cephalic part of the cartilage can then be freed from the overlying soft tissue and skin and removed ensuring symmetrical amounts are taken.
Figure 12.9 (a)-(d) Cephalic resection of the lower lateral cartilages via the cartilage splitting incision. (b) The entire cartilage mobilised from which a strip (c) from the cephalic border is incised leaving continuity, and then excised (d).
· Exposure of the nasal dorsum can then proceed as before.
· An alternative way of removing the cephalic border can be done when performing both the intercartilaginous and cartilage splitting incisions. A bipedicled chondrocutaneous flap is delivered and can be “bucket handled” into the nasal cavity allowing accurate resection of the cephalic cartilage (Figures 12.9b–12.9d).
The cartilage splitting incision does not allow full exposure of the lower lateral cartilages and is deemed a “non-delivery” approach. As such this incision will not allow adequate correction of a major tip deformity where significant manipulation of the lower lateral cartilages is required.
3. Marginal Incision
The marginal incision follows the caudal margin of the lower lateral cartilages allowing the whole cartilage to be delivered and is the choice in dealing with more complex tip abnormalities using an endonasal approach. This margin is often, but not always, at the junction of the hair bearing and non-hair bearing skin in the vestibular area.
· Exposure is enhanced by retraction of the alar margin with a wide double-pronged skin hook and pressure with the middle finger on the upper margin of the alar lobule allowing eversion of the vestibular surface of the nostril. An impression of the caudal edge is then seen and palpated (Figure 12.10a) and an incision is then made through vestibular skin.
· Dissection proceeds using sharp Iris scissors in the supraperichondrial plane on the non vestibular side (Figure 12.10b). The dissection extends to the cephalic border of the cartilage and when combined with an intercartilaginous incision allows full exposure of the whole alar cartilage (Figure 12.10c).
· The cartilages can now be inspected and modified in any required way. Marginal incisions are closed with multiple fine absorbable sutures.
Figure 12.10 (a)-(c) Marginal incision to fully expose and deliver lower lateral cartilages.
4. External Approach
Whilst many variations of the columella incision have been advocated, the broken transcolumellar inverted V incision is most commonly used and the author's preferred configuration.
Figure 12.11 (a)-(c) External approach technique.
· The incision is made in the mid columella region overlying the medial crural footplates to ensure adequate support on closure thus preventing a depressed scar (see Figure 12.11a).
· It is essential to protect the integrity of the caudal end of the medial crura just beneath the incision to prevent postoperative notching in this area. This may be done by initially making only relatively superficial incisions inside the columellar margin which extend laterally to enable reflection to expose the tip.
· These marginal vestibular extensions of the transcollumella incisions are placed 2 mm inside the vestibule and joined by careful undermining of the columella skin with sharp Iris scissors. The scissors can then be used as a guard upon which the transcolumella incision is completed (Figure 12.11b).
· It is relatively easy to identify the caudal end of each of the medial crura and use this as a guide in extending the marginal incision more laterally using angled Converse/Walter scissors with a spreading movement (Figure 12.11c). These hug the caudal surface of the cartilage and cut the overlying soft tissue.
· To obtain adequate exposure of the nasal skeleton, the marginal incision should be extended laterally at least halfway along the lateral crus. Although the major tip support mechanisms are respected in the external approach, the disruption of the skin- soft tissue envelope overlying the lower lateral cartilages and the division of the medial intercrural ligamentous fibrous tissue leads to loss of some of the minor tip support mechanisms. Some ptosis of the nasal tip should therefore be anticipated in all cases.
· The columella incision is closed with five separate 6.0 nylon simple sutures. Eversion of the skin edges ensures favourable healing and vertical mattress sutures may be needed to ensure this. The initial closure of the incision is in the midline at the apex of the inverted V. If there is any risk of tension, a subcutaneous PDS suture is used in addition to the skin sutures. The marginal incisions are closed with fine rapidly absorbing sutures.
The Operative Sequence
The sequence of surgical correction in septorhinoplasty is widely debated. Some advocate correcting any nasal tip abnormality first, prior to addressing the dorsal deformity. The advantage stated is that trying to achieve dorsal correction to match the form of the nasal tip is easier than vice versa. Further, as the external nasal splint is applied shortly after corrective osteotomies, this reduces the ecchymosis and swelling that inevitably follows. Conversely it can be argued that the more aggressive methods of dorsal reduction and osteotomies are better performed prior to the fine nasal tip work. Whichever sequence used, it is generally accepted that septal correction should precede any correction of external deformity and that alar base corrections are performed as the final part of the operation.
1. Septal Surgery (Figure 12.12a)
Septoplasty surgery is not detailed in this chapter but forms an essential and difficult part of the correction of the traumatic and functionally impaired nose. Whilst bony restoration of the dorsum may improve the upper third aesthetics, septal surgery (essentially the quadrilateral septal cartilage) is important in allowing the cartilaginous dorsum to be re-aligned.
· Caudal septal deformities can displace the leading edge of the septum from behind the columella into the nasal airway, giving rise to nasal obstruction in this area (Figure 12.12b).
· The caudal septum also provides a firm support for the columella and trauma or surgical overresection of the caudal septum may lead to columellar retraction.
· Traumatic injuries may cause fractures within the quadrilateral cartilage of the septum leading to functional problems as well as loss of support in the supratip area — the “saddle” nose. A similar appearance may occur after a traumatic sep- tal haematoma and abscess where there is necrosis of the cartilage.
· Over-resection of cartilage during septoplasty itself may also predispose to this deformity.
Figure 12.12 (a) Anatomy of the nasal septum. (b) Dislocated nasal septum leading to functional and cosmetic deformity.
· Harvesting of the quadrilateral cartilage is often required for grafting purposes. However it is important to leave substantial support for the dorsum in the form of an L shaped dorsal and caudal septal butress at least 10 mm wide.
· The rhinoplasty surgeon is required to be able to perform standard septoplasty techniques to achieve predictable functional and aesthetically pleasing results.
Correction of the Osseocartilaginous Dorsum
1. Hump Reduction
It is important to judge the extent of resection required from the dor- sum prior to local infiltration and elevation of the skin-soft tissue envelope. Attention should be given to the difference in thickness of this envelope at various aspects of the dorsum, it being thinnest at the rhinion, the lowest and most prominent point of the internasal suture. The dorsal hump consists of a bony and cartilaginous component. Endonasal approaches give more restricted views of this area but exposure is maximised by placing an Aufricht retractor along the dorsum under the skin and soft tissues (Figure 12.13).
External rhinoplasty exposure of the upper third of the nose may allow more accurate diagnosis and precise correction, although lack of traction of the tissues makes judgement more difficult.
• The initial incision occurs through the cartilaginous dorsum at the decided level by cutting through the cartilage from cephal- ically at the osteocartilaginous junction downwards caudally (Figure 12.14a).
Figure 12.13 Aufricht retractor placed along dorsum of nose in endonasal approach.
Figure 12.14 (a)-(d) Removal of dorsal hump.
· An osteotome can now be placed under the resected cartilage fragment with its edge facing the bone cephalic to this (Figure 12.14b). It is important at this stage to ensure the osteotome is held in a perfectly horizontal plane to ensure symmetrical bony removal (Figure 12.14c). The exception to this is when excising a bony hump in the presence of a bony pyramid deviation with nasal bones of unequal height. In this case the plane of the osteotome must be altered. An assistant performs a series of double taps with a mallet onto the osteotome to initially engage and then cut through the bone. If the soft tissues have been adequately mobilised, an en-bloc osteocartilaginous hump can be removed. This resected fragment is boat shaped and should consist of part of the nasal bones and the upper laterals/cartilaginous septum complex.
· Symmetry of resection of these structures is checked on the removed fragment. Coarse tungsten-carbide rasps can now be used to “fine tune” the dorsal resection to remove any significant excess bone and finer diamond rasps used to smooth any irregularities in the resected bone (Figure 12.14d).
· An important final step here is to turn the rasp upwards and gently sweep under the skin and soft tissue for removal of any small residual fragments which may otherwise be palpable or visible as postoperative irregularities.
· Rasping of the dorsum alone without using the osteotome is advocated by some surgeons. Due care is advised using this method as repeated use of a rasp may inadvertently traumatise the overlying skin, especially when thin, which can cause some persistent erythema. Bony reduction with powered instrumentation is a new and elegant alternative to the osteotome.
A common mistake is resection of the bony hump without appropriate reduction of the cartilaginous vault. This risks leaving a “pollybeak” deformity which can also occur secondary to soft tissue scarring when the plane of dissection in this area is incorrect (Figure 12.15).
Figure 12.15 Pollybeak deformity in a revision rhinoplasty patient.
2. Osteotomies
Mobilisation of the bony vault is achieved by osteotomy. The bony pyramid may need
· re-alignment if deviated,
· narrowing at the base, or
· closure of the “open roof” that is an inevitable consequence of hump reduction.
Many aspects of the technique have been refined to produce predictable results with minimal ecchymosis and oedema.
· Local infiltration of the tissues lateral and medial to the bony vault with lidocaine and adrenaline is helpful in reducing bleeding. Microosteotomes are used and should be sharp and small (approximately 2–3 mm).
Medial osteotomy
The medial osteotomy extends from the caudal bony vault upwards in a slightly oblique fashion (Figure 12.16a).
• The osteotome is introduced intranasally and engaged into and advanced along the medial aspect of the nasal bone. A distinct note change is usually heard if the thicker frontal bone is reached. This medial fracture controls the site where a lateral bony back fracture occurs.
Figure 12.16 (a) Medial osteotomy. (b) Lateral endonasal “high-low-high” osteotomy. (c) Lateral percutaneous osteotomy.
Lateral osteotomy
The lateral osteotomy may be performed endonasally or percutaneously.
Endonasally;
· A stab incision is made intranasally in the mucosa overlying the pyriform aperture just above the attachment of the inferior turbinate to the lateral nasal wall.
· A thin guarded microosteotome is used, designed to preserve the medial periosteum and a laterally positioned guard allows palpation of the edge of the osteotome at all times. The so called high–low osteotomy refers to the supine patient where the upper nasal bone area is “high” and the lower bone is “low”.
· The “high-low-high” osteotomy proceeds as follows: initially the osteotome is introduced high on the lateral wall of the pyriform aperture (Figure 12.16b). The osteotomy is extended down to and then lowalong the nasofacial groove. As it is extended upwards it is slowly curved from lateral to medially and ends high at the level of the medial canthus . This leaves a small triangle of bone at the base of the pyriform aperture which, if infractured, may lead to nasal blockage.
Extension of the lateral osteotomy beyond this level into the thicker nasofrontal bone risks a “rocker deformity” where infracture of the nasal bone causes protrusion at the superior fracture site. If a medial osteotomy has been performed, a controlled back fracture is achieved by twisting the osteotome medially.
The lateral osteotomy may also be performed percutaneously.
· Stab incisions are made through the skin at two points; midway between the medial canthus and the edge of the pyriform aperture
· low in the nasofacial groove and superiorly between the medial canthus and the top of the dorsum (Figure 12.16c).
· A sharp 2 mm microosteotome is introduced and a series of perforations are made low along the lateral nasal wall and a superior osteotomy is fashioned with perforations at the level of the medial canthus.
· Each perforation is made to go through the bone but not the medial periosteum. As the bone is perforated a distinct change in tone (fall in pitch) is heard with the tapping sounds.
· Studies have shown that the small stab incisions are entirely invisible postoperatively. The percutaneous lateral osteotomy is simple to learn and execute and allows precise, predictable fractures to be made.
Intermediate Osteotomy
The intermediate osteotomy is used to correct an extreme deviation of the nasal pyramid where one nasal sidewall is far longer than the other. Medial and lateral osteotomies alone in this case could not create bones of equal height and residual postoperative deviation is the norm. The intermediate osteotomy effectively shortens the longer side allowing the nasal bones to be repositioned into the mid line. When performed bilaterally it can be used to narrow a very wide nasal dorsum. The osteotomy is placed along the mid aspect of the lateral nasal wall and it is important to perform it prior to the lower lateral osteotomy as it cannot be done if the lateral wall is mobile.
Nasal Tip Surgery
Surgery of the nasal tip is by far the most complex aspect of rhinoplasty surgery and requires a sound appreciation of the anatomy and aesthetic facial parameters. Preoperative assessment should define what specific anomalies are present and the objectives for correction.
The problems encountered may be thought of as being due to
· volume excess,
· under- or overrotation,
· under- or overprojection,
· width problems, or
· intrinsic tip deformities.
It is beyond the scope of this chapter to describe each aspect of complex tip correction in detail. The basic concepts can be divided into
· volume reduction,
· tip remodelling procedures,
· placement of (usually) cartilaginous grafts.
Projection and rotation of the tip are intricately related and manoeuvres to correct one may well affect the other.
The tripod concept of the nasal tip is a very useful model to predict changes in these parameters with modifications of the alar cartilages, and is detailed later.
Volume Reduction
Where there is isolated volume excess of the nasal tip giving rise to bulbosity, cephalic resection of the lower lateral cartilage may be adequate to increase definition and cause mild narrowing (see Figures 12.9a–12.9d). Access to the cephalic border of this cartilage as previously described may be via a cartilage splitting incision or by retrograde dissection from an intercartilaginous incision. The external approach is not required for isolated cephalic reduction but precise and symmetrical resection is optimal using this technique.
Judgement is critical in ensuring enough cartilage is removed to give a noticeable change in the definition but leaving as much cartilage behind as possible. Overzealous cephalic strip resection can lead to a “visoring” effect due to alar retraction caused by contraction as healing occurs. An absolute minimum of 8 mm width of residual cartilage continuity is recommended but in the presence of an anatomically narrow alar cartilage this may need to be reconsidered. If vestibular mucosa is not preserved, this too can contribute to contracture and promote further retraction.
When employing an endonasal approach, marking in the vestibular area is useful to ensure the incision is made in the correct position — an instrument can be used to make an imprint in the vestibular skin or a needle placed percutaneously in the appropriate place. Symmetrical reduction is essential — both resected cartilages are compared to ensure this is the case.
Following reduction, a small void is created in cephalic region of the lower lateral cartilages. Healing and contracture may cause some upward rotation of the tip to fill the void. Overall this is often a favourable change although care should be exercised in an already overrotated tip. This method cannot be relied upon as a powerful or indeed completely predictable method of causing significant tip rotation.
Rotation Deformities (Figure 12.17a)
Correction of the underrotated tip can be done with various manoeuvres based on the tripod concept. This concept proposes that the conjoint medial crura are one limb of the tripod with each lateral crus representing a separate lateral limb (Figure 12.17b). Manipulation of any part of the tripod can be used to predict changes in the projection and rotation of the nasal tip. The LeFort I maxillary advancement will correct an underrotated tip by advancing the conjoint medial crura and caudal septum. Most rhinoplasty techniques for rotation problems rely on the tripod manoeuvres of the nasal tip.
Figure 12.17 (a) Surgical anatomy terminology. (b) Tripod model of lower lateral cartilage dynamics. The tripod limbs represent the two lateral crurae and the conjoined medial crurae as the third limb.
· Thus division and overlay of the lateral crura will produce a marked tip rotation upwards, but will also cause some tip deprojection (Figure 12.18a).
· Lateral crural steal techniques which recruit the lateral crura medially using domal suturing can enhance rotation and also be usefully employed for increased projection (see also projection deformities below) (Figures 12.19aand 12.9b).
An over rotated nasal tip is an unaesthetic “piggy nose”. Options for correction are more limited with this situation.
· A graft in the tip/infratip area will give an illusion of counter-rotation and increased length of the nose.
· A caudal septal extension graft also gives a similar effect.
· In order to accomplish counter-rotation in extreme cases, a skin-cartilage composite graft may be needed in space created between the upper and lower lateral cartilages.
Figure 12.18 (a) Division and overlay of lateral crura to cause tip rotation. (b) and (c) Dome suturing technique.
Figure 12.19 (a) and (b) Lateral crural steal technique to increase tip projection.
· Division and overlap of the medial crurae is another option, although this also deprojects the tip.
Projection Deformities
Increasing the projection of the nasal tip is often desirable in rhino- plasty surgery. As with rotation problems, this can be achieved by reorientation of the alar cartilages or by addition of cartilaginous struts or grafts. Variations of basic techniques are widely described. Commonly performed procedures include the following:
1. Domal Sutures
Suture modification of the nasal domal area can refine the shape of the nasal tip into a more aesthetic configuration.
· Domal sutures can convert a “boxy” or trapezoidal configuration of a nasal tip into a more aesthetic triangular configuration (Figures 12.18b and 12.18c). Sutures are placed within an individual dome (intradomal or a single dome unit) and the two domes can then be approximated (interdomal or a double dome unit).
· Mild projection of the nasal tip can also be achieved by transdomal suturing using 6.0 nylon, that causes the domes to be elevated.
· To increase the projection even further, the lateral crus of the lower lateral cartilage is mobilised fully from the vestibular skin. This lateral crus can then be recruited towards the domal area and a new dome created and sutured in a newly projected position — the so-called “lateral crural steal” (Figures 12.19a and 12.19c). This procedure also causes a degree of tip rotation.
· Vertical dome division with resuturing — The Goldman technique is the original and perhaps most well described method of dome division. The many modifications of this technique all describe vertical division of the lower lateral cartilage usually 2-3 mm lateral to the existing dome. The medial cut ends of cartilage are then sutured back to back thereby increasing projection of the tip and can be trimmed to the exact height required and if required, can be shortened to deproject the tip (Figures 12.20a) and 12.20b). The residual lateral cartilages are left and generally prolapse medially. Vestibular skin may be preserved intact although the original description of this technique suggested incision through this. Current management of the nasal tip has veered away from this technique towards suture modification. Criticisms of its use have included its relative irreversibility and the creation of a very sharply defined, “tent pole”-like appearance to the tip particularly in the presence of thin skin.
Figure 12.20 (a) and (b) Goldman technique of dome division.
These techniques are, however, still very useful and with appropriate selection of patients give excellent form to the tip.
2. Grafts and Struts
Autogenous grafting material is always a preferred source of tissue. Grafts are usually harvested from the quadrilateral cartilage of the septum or auricular conchal bowl (Figure 12.21). Placement on the nasal tip region can cause projection changes. Dependent on the area required for projection, various cartilage grafts have been described. Grafts are sutured into place using fine non-absorbable sutures when performing an external approach, or by specific placement in precise pockets if approached endonasally.
Figure 12.21 Harvest of auricular cartilage via an anterior approach.
The columellar strut is extremely useful in maintaining and to some extent increasing tip projection. With the inevitable loss of tip support with any of the described approaches, ptosis may be anticipated in the postoperative period and placement of a cartilaginous strut between the medial crurae can help prevent this (Figure 12.22).
Placement of grafts in the premaxillary region can be sometimes used to give an illusion of tip rotation and projection.
Deprojection of the tip is less often required and can necessitate a number of manoeuvres based on the tripod concept.
· Division of the medial crural footplate attachment to the caudal septum with an extended full transfixion incision will lose one of the major tip support mechanisms and should cause some deprojection and counter-rotation.
· Vertical division of the alar (lower lateral) cartilages with overlay and suturing of the edges should also decrease projection. Such an overlay can be fashioned in the lateral crurae to give increased rotation and decreased projection.
Figure 12.22 Insertion of cartilaginous columellar strut.
Other techniques include:
· Reduction of the nasal spine.
· The previously described vertical dome division with excision of the excess medial crurae and reconstruction with sutures.
· The “tongue-in-groove” technique of septocollumellar suturing remains a further option and is a useful way of establishing both projection and rotation of the nasal tip. A disadvantage of this method is the rigidity and lack of mobility such a procedure imparts to the tip in some patients.
Alar Base Reduction
Assessment of the alar base is made preoperatively and reduction planned if required. Change in tip dynamics may influence the alar base width perioperatively such as in marked deprojection of the overprojected “tension” nose. In this case, the alar base is generally flared as a result of the other corrective procedures and the patient should be told of the possibility of needing reduction.
Alar base reduction is generally divided into correction relating to excess alar flare, excess nostril size or a combination of these. It is universally agreed that alar base reduction is performed as a final step in the operation after all other deformities have been corrected. Conservative reduction is important to avoid the complications of asymmetry and over-reduction which are both difficult to correct.
Nostril Size
Excision of a wedge of skin and soft tissue from the nostril floor alone will reduce the internal dimension of the medial border of the nostril (Figure 12.23a). Subtle alteration of the alar curve can be effected too, but this manoeuvre will not affect the width of the alar bases.
Alar Flare
More marked changes in alar flare are achieved by extension of an incision within the nostril into the alar facial junction.
· The incision is not made within, but rather 1-2 mm above the alar facial crease as this minimises postoperative scarring and visibility. A wedge is removed from this area allowing reduction in the bulkiness of the ala and the width of the base can be narrowed as well (Figure 12.25b).
· If significant alar flare reduction is needed a larger wedge is excised and a small back cut onto the lateral edge of the nostril facilitates adequate medialisation of the alar bases (Figure 12.23c).
Combination
The combination of alar flare and excess nostril size is corrected with a rectangular shaped resection of alar tissue. Symmetrical marking of the excision is critical to diminish the postoperative dissatisfaction of asymmetry (Figure 12.23d).
Eversion of the skin edges with fine non-absorbable sutures (6.0 nylon) are used to ensure an accurate closure.
Figure 12.23 (a)-(d) Techniques for alar base reduction.
Postoperative Care
Generally, meticulous technique and closure can avoid the need for postoperative nasal packing altogether and this is preferable as the presence and removal of such packs can be extremely uncomfortable. Packing materials, if required, include nasal tampons, ribbon guaze packing that may be impregnated by Bismuth Iodoform Paraffin Paste (BIPP) or non-stick dressings such as Telfa or Melonin. Packing is generally removed a few hours after surgery although can be left overnight.
Intranasal silastic splints are generally not required but are used in patients in whom postoperative synaechiae between the lateral wall of the nose and septum are a risk. Such patients include those with preoperative nasal adhesions from prior trauma or surgery or those who have significant perioperative septal mucoperichondrial tears. Splints are also used routinely after septal perforation closure. Silastic splints are available preformed or may be custom-made from sheets and are sutured to the nasal septum anteriorly. The splints are removed two weeks postoperatively in the outpatient setting.
A dorsal dressing is applied at the end of surgery to stabilise the nasal bones following osteotomies. Initially, steristrips are placed firmly along the dorsum to help re-approximate the dorsal skin and soft tissue envelope to the underlying skeleton. It is important to place one strip across the nasal tip area moulding and holding the tip into a desired position whilst the healing process occurs. Many options for the splint are available including preformed thermoplastic and metallic splints and the author's favoured custom tailored Plaster of Paris. A5-layer 5 cm × 5 cm triangle of plaster is used. The sharp squared edges are rounded off into gentle curves in particular to ensure the cephalic edge of the plaster does not impinge upon the medial canthus of the eye. The plaster is soaked in warm water and is applied over the steristrips and held firmly whilst it sets and fixes the bony dorsum in the desired position. This creates a small but adequately protective splint that is further secured by taping over the plaster onto the face thereby ensuring it remains in position. Brown coloured micropore is used to act as an effective camouflage of the plaster itself (see Figure 12.24). The dorsal plaster splint is removed a week postoperatively as are any external sutures.
Figure 12.24 Nasal splint.
Revision Surgery
Revision corrective procedures remain one the most challenging aspects of rhinoplasty surgery. As techniques evolve, the rhinoplasty surgeon is ever seeking an ultimate postoperative result that will please both the discriminative patient and surgeon alike. New computer-aided preoperative techniques aimed at predicting eventual improvement in cosmesis coupled with the unprecedented number of media articles on cosmetic surgery appear to be increasing patient expectations. The inadequately informed patient is likely to be more critical of postoperative results. Increasing rates of revision surgery may be predicted in Europe, reflecting trends in North America.
The need for revision rhinoplasty may arise from either inadequate or overzealous primary surgery, most often the result of poor judgement by an inexperienced surgeon. Furthermore, postoperative scarring can turn a shorter-term good cosmetic result into a suboptimal one with time. In both cases, the resultant localised loss of contour or deficiency of the support mechanisms may in turn be associated with functional problems.
The revision rhinoplasty patient may further present with psychological issues including the body dysmorphobic disorder, relating to the original surgery and these must be both recognised and addressed during any preliminary consultation. In doing so, the important distinction between a patient-perceived or truly inadequate postoperative result can be made. In the former case it is particularly important not to convey false expectations regarding a revision procedure to the expectant patient. A doctor/patient rapport must be built laying the foundations for extended counselling in order to convey a realistic outcome for any revision surgery. Where a personality disorder is apparent, referral to a clinical psychologist or liaison psychiatrist may be essential.
Figure 12.25 Basic rhinoplasty instruments. Instrument list (from left to right), Top row: Cottle's speculum, double pronged wide hook, single/double pronged micro hook, Aufricht retractor, Joseph periosteal elevator, Brown-Adson toothed forceps, Blakesley-Wilde forceps. Bottom row: Osteotomes — 14 mm/10 mm/ guarded 2.2 mm/2 mm, tungsten carbide glabella rasp, tungsten carbide dorsal rasps, Walter scissors, Kilner scissors, Foman scissors.
Retrospective analyses have identified lower-third deformities followed by middle-third deformities as the most commonly encountered problems requiring secondary surgery.
Most authors would agree that revision surgery should not be planned for at least one year following the last operation. This time allows maturing of scar tissue, diminishing the risk of further deformity due to poor tissue healing following subsequent surgery. Whilst this remains a good general guideline, early correction of minor deformities such as an inadequate osteotomy may allay patient anxieties without compromising overall results. Other deformities that may be similarly rectified at an early stage include alar base widening that may be evident following the original surgery, alar retraction and minimal bony dorsal deformities requiring little soft tissue dissection. The majority of revisions, however, are best deferred and a clear explanation regarding the reasoning will usually temper patient pressure. The advantage of soft mature scar tissue during the revision operation facilitates easier dissection. “Shrink-wrapping” of the skin over the structural components is also well established by a year and will identify any irregularities at this stage, although the overall process continues further for some years. However, nasal tip revision surgery may need to be deferred somewhat longer than 12 months as adequate healing and shrink-wrapping may not be complete.
A particular challenge in revision rhinoplasty surgery is the unpredictability of the findings during surgery. Soft tissue contractures and scarring may mimic underlying structural deformity, and even with meticulous planning, the surgeon must remain able to adapt or even change the planned techniques to suit the discovered anomaly. Camouflage grafts are not always predicted for use but should be considered as being required to help correct such unforeseen deformities when formulating the preoperative plan. Experience in a variety of techniques is naturally a prerequisite to undertaking this sort of procedure due the very nature of this unpredictability.
Case Reports
Three cases are presented as examples of the complexity of the rhinoplasty challenge (see Figures 12.25 to 12.27).
Patient Examples
Patient 1 — Dorsal Hump and Tip Ptosis
Problems: Dorsal hump, slight deviation of bony dorsum, low take off point of nose from face, ptosis of nasal tip, excess columellar show. Retrognathia — patient not seeking correction of this.
Important Considerations: Large dorsal hump reduction may be the initial intervention for an inexperienced rhinoplasty surgeon. This would lead to a overlong, ptotic looking nose which would be more unaesthetic than the initial presentation. Projection and rotation of the tip here is the key to improving the nasal balance. The “take off point” of the nose is also very low on the face with a shallow nasion — an ideal being approximately at the level of where the upper eyelashes point to on the lateral view. Augmentation of the radix area together with the tip changes mean a much smaller dorsal hump reduction is required.
Surgical Plan: External approach septorhinoplasty; lateral crural steal and suturing to rotate and project tip, minor cephalic volume reduction of lateral crurae, columellar strut harvested from septal cartilage for support, reduction of caudal and membranous septum, dorsal bony and cartilaginous dehump (minor), medial and lateral endonasal osteotomies, crushed radix graft harvested from septal cartilage to augment nasion.
Patient 2 — Post-Traumatic Saddle Deformity
Problems: Post-traumatic saddle deformity, scar overlying dorsum, bony deviation to right, columellar retraction, broad nasal tip (patient unconcerned regarding this). Nasal obstruction with internal nasal valve collapse.
Important Considerations: Given the extent of the saddle deformity, septal cartilage harvest would be impossible and alternative sources are required. Scar revision, if required, should be deferred.
Surgical Plan: External approach rhinoplasty; auricular cartilage harvest for augmentation of dorsum with 2-layer graft, columellar strut and spreader grafts, tip refinement with dome suturing, medial and lateral percutaneous osteotomies.
Patient 3 — Shallow Dorsal Hump and Boxy Tip
Problems: Dorsal hump, wide, “boxy” configuration to nasal tip with excess cephalic volume of lower lateral cartilages. Nasal obstruction with septal deviation and idiopathic perforation.
Important Considerations: Subtle improvements are only required here for restoration of cosmesis and improvement of brow-tip aesthetic lines.
Surgical Plan: Septorhinoplasty with closure of septal perforation; minor dorsal bony and cartilaginous dehump, medial and lateral endonasal osteotomies, dome suturing of lower lateral cartilages and volume reduction of cephalic margins. Septal perforation closure with bipedicled mucoperichondrial flaps and interpositional graft.
Conclusions
Rhinoplasty surgery is a complex aspect of aesthetic and reconstructive surgery of the face. Its important relationship to other orthognathic procedures is clear and the principles outlined in this chapter should provide a sound understanding of the basic concepts of this type of surgery.
The wide array of operative techniques involved in rhinoplasty necessitates a thorough understanding of the anatomy of the osseocartilaginous vault and septum, surgical principles and healing processes associated with these operations.