23 Problems Involving the Nasal Vestibule
Scar induration and distortion, stenosis, asymmetry, retraction, and recurrent or residual deviation of the anterior septum are not uncommon findings in previously operated noses. The nasal vestibule is the site for placing incisions for both endonasal and open approaches. 1 Unfavorably placed incisions or displaced alar cartilages may lead to contractures and troublesome step-offs or distortions in the “gull in flight” configuration of the alar cartilages. Individual findings will determine the specific corrective approach that should be used in any given case. It is usually sufficient to make minimally invasive corrections based on individual findings ( Fig. 23.1 ). 2
Case 25
This case involves an extracorporeal septoplasty with repositioning of the deviated nasal spine and a lateral sliding technique (operation by Wolfgang Gubisch).
Introduction
After six previous operations elsewhere, the patient was dissatisfied with the functional and aesthetic outcome of her procedures. She had a deviated nose with a displaced anterior nasal spine. The vestibule and nasal tip were asymmetric, and the patient had breathing problems due to a deviated septum and tight internal valves.
Findings
Inspection of the nose in the frontal view ( Fig. 23.2a ) showed disharmony of both brow-tip aesthetic lines. In the profile view ( Fig. 23.2c ), several conspicuous irregularities were apparent in the nasal dorsum. The nasal tip was asymmetric and undefined ( Fig. 23.2a, b ). The bony pyramid was deviated. In the basal view, the columella was deviated to the right and its base was to the left of the midline. The anterior nasal spine was also found to be off-midline when palpated. Endonasal inspection revealed a deviated septum. Manual expansion of the internal nasal valve with a glass rod immediately improved nasal airflow, confirming that the internal valves were stenotic and required reconstruction.
Surgical Procedure
An open approach was performed through the old scar using a standard inverted-V midcolumellar incision. Tip dissection was very difficult due to heavy scarring in that area ( Fig. 23.2g ). On dissecting the scars, we found an old cartilage graft on the right dome. When that graft was removed, it was apparent that the left dome occupied a higher position. For that reason a lateral sliding technique was performed on the left side ( Fig. 23.2j ). The nasal septum was deviated, especially in its anterior cartilaginous part. The septum was also highly unstable due to extensive cartilage resections in previous operations. Therefore we decided to remove the septum in one piece and perform an extracorporeal septal reconstruction ( Fig. 23.2h ). After smoothing all irregularities and thinning out the thickened portions of the perpendicular plate, we fixed the thin bony part of the septum to the cartilaginous part for straightening and stabilization ( Fig. 23.2i ). Because the anterior nasal spine was 8 mm to the left of the midline, we had to fracture the spine, return it to the midline, and secure it with a microplate. Conchal cartilage taken from the right ear was used to fashion a sandwich graft, which was placed as a columellar strut to stabilize the anterior septum. Conchal cartilage was also used to make spreader grafts, which were fixed to the dorsal border of the reconstructed septum to reconstitute the internal valves. Then the straight neoseptum was returned and fixed dorsally to the upper lateral cartilages with multiple back-and-forth sutures. It was also fixed to the repositioned anterior nasal spine with several sutures. We performed direct lateral, paramedian, and transverse osteotomies on both sides to correct the bony pyramid. The irregularities in the bony dorsum were smoothed out. The dorsum was additionally covered with three layers of homologous fascia lata. Finally we corrected the nasal tip with transdomal sutures, a spanning suture, and a tip suspension suture.
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