25 Augmentation of the Nasal Dorsum
The nasal dorsum runs from the root of the nose (radix) to the nasal tip. It extends over the bony and cartilaginous portions of the nasal pyramid. The area of the rhinion, or keystone area, has a major role in providing structural support. The internal nasal valve has special functional importance. Between the keystone area and nasal valve region is the middle vault, which is formed chiefly by the upper lateral cartilages. The upper lateral cartilages curve toward the nasal dorsum like the arches of a Gothic cathedral and are supported there by the septal cartilage. Together the upper lateral cartilages and septal cartilage comprise an anatomic unit. 1 , 2
Saddling, irregularities, and deviations may be congenital, postinflammatory, posttraumatic, or iatrogenic due to previous surgery. Before reconstructing the nasal dorsum, the surgeon should first evaluate how the dorsum and tip are contributing to structural support. 3 This is done by inspection and especially by palpating the nasal tip and assessing supratip recoil. Augmentation is sufficient in noses with adequate protection and projection. If the nasal tip is not stable enough, it should be supported with a columellar strut to create an anterior pillar for the nasal dorsum.
Case 30
Introduction
The patient, now 38 years of age, underwent a septoplasty in 1990. Two years later she developed saddling of the nasal dorsum. She had surgery to correct the saddle nose in 1992, and another revision was done in 1999 for the same indication. Later the patient sustained facial trauma that included an open wound over the nasal dorsum. In 2004, an implant was placed to support the nasal dorsum and a scar revision was performed. She presented now with a persistent saddle nose deformity.
Findings
Posttraumatic saddle nose after four previous nasal operations, bilateral otoapostasis, and bilateral acute recurrent rhinosinusitis.
Frontal view ( Fig. 25.1a ) shows marked saddling of the middle vault and supratip area with a scar over the nasal dorsum. Profile view ( Fig. 25.1b ) shows a pseudohump with cephalic tip rotation and an obtuse nasolabial angle. Basal view ( Fig. 25.1c ) shows a somewhat broadened nasal tip due to lateralization of the alar cartilages.
Fig. 25.1d , Fig. 25.1e , and Fig. 25.1f show the corresponding views 2 years after revision surgery. Tip recoil indicates satisfactory tip protection.
Surgical Procedure
A setback otoplasty was performed, and a revision rhinoplasty was performed through an intercartilaginous approach. Bilateral spreader grafts were placed to stabilize a weak “septal bridge.” An onlay graft was placed in the supratip area, and the entire middle vault was augmented. Medial and lateral curved osteotomies were performed on both sides. Sinus problems were addressed by performing an infundibulotomy and supraturbinate antrostomy and establishing frontal sinus drainage with a Draf IIa procedure ( Fig. 25.1g ).
Psychology, Motivation, Personal Background
The odyssey of nasal operations, disappointments, and then a successful revision ruined by nasal trauma had left the patient with a “psychic wound.” So while she wanted definitive closure on her nasal and sinus issues, she was reluctant to subject herself to another nasal operation and was pessimistic about the outcome.
Discussion
The decision to use autologous conchal cartilage was facilitated by the patient′s desire for an otoplasty. Given her prior history, rib cartilage with its high mechanical stability would have been an option. The advantage of elastic conchal cartilage is its flexibility and its association with a thick layer of connective tissue, which can provide soft, harmonious support for the nasal dorsum. A stiff costal cartilage graft is bothersome for some patients, even with a good aesthetic outcome.
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