33 Iatrogenic Overresection of the Nasal Framework

10.1055/b-0035-121711

33 Iatrogenic Overresection of the Nasal Framework

In cooperation with Wolfgang Gubisch

Case 52

This case involves a severe deformity of the nasal tip with loss of support to the anterior septum (operation by Wolfgang Gubisch).

Introduction

After undergoing two previous operations elsewhere as a child, the patient suffered from an unusual aesthetic deformity of the nasal tip and a severe impairment of nasal breathing.

Findings

Inspection revealed a conspicuous deformity of the nasal tip with loss of tip support and projection ( Fig. 33.1a–c ). The tip defining points were spaced far apart, and the tip appeared completely undefined ( Fig. 33.1a, b ). On palpation, the anterior part of the septum and anterior nasal spine were found to be missing. Internal examination revealed a severely deviated septum.

**Fig. 33.1** Pre- and postoperative views. (a) Preoperative frontal view shows a severe deformity of the nasal tip and a short nose. The tip defining points are too far apart. The nose is disharmonious with the rest of the face. (b) Lack of tip definition is appreciated in the basal view. (c) Profile view shows the loss of projection. There is a conspicuous loss of tip support and definition. (d) Frontal view one year after revision rhinoplasty. The tip is corrected, and nasal length is in harmony with the rest of the face. (e) Basal view after the revision. (f) Profile view one year after revision rhinoplasty documents the correction of tip projection and tip support. (**g–j**) Intraoperative views. (g) Intraoperative view of scarring at the nasal tip. (h) View after fixation of the septal extension graft (double-layer conchal cartilage graft). (**i, j**) Reconstruction of the lower cartilages by the bending technique. (i) The strips of costal cartilage are fixed medially to the stumps of the medial crura. (j) The new alar cartilages are sutured laterally to the vestibular mucosa and are joined together medially with an intercrural suture.

Surgical Procedure

An open approach was done through a standard inverted-V midcolumellar incision. Analysis showed massive scar formation at the nasal tip ( Fig. 33.1g ). After dissecting the tip, we found that the lower cartilages had been overresected and the remaining cartilages were deformed. The anterior nasal spine was missing. The anterior part of the septal cartilage was absent and the rest was deviated. When the scars at the nasal base were dissected, the septal cartilage became straight. Conchal cartilage was harvested on one side, and a double-layer conchal sandwich graft was placed as a septal extension graft ( Fig. 33.1h ). The sandwich graft was fixed to the premaxilla through a V-shaped drill hole in the area of the missing anterior nasal spine and also to the anterior border of the septal cartilage. We used the bending technique for reconstruction of the lower cartilages ( Fig. 33.1i, j ). ¹ ^, ² Costal cartilage was harvested because there was not enough material in the septum and not even enough conchal cartilage for a cartilaginous reconstruction. Two strips of costal cartilage were sculpted with a bur to create a defined arch in the new dome area. The new alar cartilages were sutured medially to the stumps of the medial crura and also to the septal extension graft. Laterally they were affixed to the vestibular mucosa. The tip was reshaped with inter- and transdomal sutures and a spanning suture.

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Tags: Audiology, Oral and Maxillofacial Surgery;Plastic, Otorhinolaryngology, Phoniatrics, Reconstructive and Cosmetic Surgery, Section II, The Nose-Revision & Reconstruction

Jun 9, 2020 | Posted by drzezo in OTOLARYNGOLOGY | Comments Off

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33 Iatrogenic Overresection of the Nasal Framework