12 Lateral Osteotomies
In 1898, Jacques Joseph described his technique for performing a lateral osteotomy with a saw. Later, in the 1920s, chisels and osteotomes became the instruments of choice for lateral osteotomies. The trend in later decades was toward a low-to-high osteotomy. Webster 1 and Farrior 2 described the high-low-high osteotomy as a technique for preventing functional stenosis of the nasal airway. The introduction of micro-osteotomes by Tardy 3 contributed greatly to minimizing tissue trauma by helping to preserve the periosteum and intranasal mucosa in lateral osteotomies. Nowadays, powered instruments are available.
The selective division and repositioning of the bony nasal pyramid is an essential step in rhinoplasty. Every bone cut should be carefully planned and executed, because a technically flawed osteotomy is extremely difficult to correct. Thus, the selection of osteotomes and optimum technical proficiency will greatly influence the success of a rhinoplasty.
It is often said that an aesthetic rhinoplasty should never improve appearance at the cost of function. Osteotomies do affect nasal breathing, however, and may significantly alter the width of the nasal valve region.
Guyuron 4 was able to show that lateral osteotomies almost always cause narrowing of the nasal airway. The length of the nasal bones, the degree of medialization of the osteotomized fragments, the position of the inferior turbinate, and the type of osteotomy are key factors that determine the functional result. In this regard, low-to-low osteotomies tend to have a better functional outcome than low-to-high osteotomies.
The principal risks of lateral osteotomies are postoperative asymmetry, instability of the fragments, nasal valve stenosis, and inward displacement of the lateral nasal wall. 5 This should motivate the surgeon to preserve as much periosteum as possible to give support to the mobilized fragments. Whether this is achieved better with continuous endonasal micro-osteotomies 3 or percutaneous perforating osteotomies 6 is open to discussion and depends on the above requirements and the technical proficiency of the surgeon.
12.1 Technically Flawed Osteotomies
The following examples show typical problems after osteotomies ( Fig. 12.2 , Fig. 12.3 , Fig. 12.4 ) and one clinical case ( Fig. 12.5 ).
12.2 Revision Osteotomies
12.2.1 Case Report
Young lady two years after septorhinoplasty. We see a removal of higher cartilages from the nasal pyramid on the right side after an incomplete lateral osteotomy, steep position of both osteotomized fragments, open roof ( Fig. 12.6a–e).
12.2.2 Surgical Procedure
Osteotomies and rhinoplasties in general require an individualized approach. It is important to consider the length of the nasal bones, the thickness of the bone, the age of the patient, and the expected brittleness of the bone. With these factors in mind, the surgeon can select the osteotome that is most suitable for a particular osteotomy. 7
In principle, bone can be divided with chisels or osteotomes. Chisels are beveled on one side only and tend to deviate toward the beveled side. Osteotomes have two beveled surfaces. If the bevels are equal on both sides, the osteotome will tend to cut in a straight line.
The bevel angles should ensure that the osteotome produces an optimum cutting action in the bone without grabbing and without splintering the bone.
Equal bevels allow the osteotome to glide straight ahead. By varying or fine-tuning the lengths of both cutting edges, a variable “curved track” can be designed into the osteotome blade. 8
We have adopted this concept from speed skating. The speed-skate blade is not straight but has a certain radius of curvature. Speed-skate blades have a different curvature than figure skates, for example. We have adopted and modified this concept in creating the directional bevel osteotome ( Fig. 12.7 and Fig. 12.8 ). 9
Our task group in Berlin has been working with Karl Storz Endoscopes for many years to develop improved and innovative osteotome designs. The search for the ideal osteotome is a fascinating challenge ( Fig. 12.9a, b ).
Smooth, atraumatic bone cuts are the most important prerequisite for an ideal result. Most “salvage operations” after rhinoplasties and most indications for revision rhinoplasty are based on irregularities, asymmetries, and deformities of the nasal skeleton or nasal dorsum. 9
Incompletely mobilized fragments should never be “pried out” because this would tear the periosteum, leading to protracted swelling and ecchymosis over the nasal pyramid. The stronger the periosteal and soft-tissue reactions, the greater the tendency for scarring, persistent induration, or callus formation. The designated fragment should therefore be circumscribed and mobilized as accurately as possible. 10
The cutting action of an osteotome depends critically on the composition and hardness of its steel. The steel should be hard but not brittle so that it can glide “elastically” through the bone—a difficult concept to picture. Brittle steel tends to become chipped or pitted along its cutting edge. The hardness of steel depends on its alloy composition and can be measured on the Rockwell scale. The alloying process and specific production steps are the “stuff that dreams are made of” and, like the formula for Coca-Cola, are secret.
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