Introduction

This 68-year-old woman presented with extrusion of a nasal implant. When she was 17 years old, the L-shaped plastic splint had been inserted for dorsal augmentation. Forty years later a slowly progressing atrophy of the surrounding tissue and formation of spider veins affected the appearance. The visible extrusion in the tip area developed within 4 weeks, painless and without other symptoms ( Fig. 34.1a–c ) (operation by Joachim Quetz).

Diagnosis

Inspection showed a prominent contour of the implant tightly encased by atrophic skin with conspicuous spider nevi. The defect at the tip had a diameter of 4 mm (bottom) extending to 6 mm (outside edges) with the exposed implant in the center. The wound edges were epithelialized and showed hardly any signs of inflammation. Palpation of the nose revealed a highly atrophic and inelastic skin around the surface of the implant, while the glabella region showed a dilatable skin. Aim of the upcoming operation was removal and replacement of the implant by rib cartilage grafts, ¹ reinforcement of the skin, and, preferably primary closure of the defect.

Surgical Procedure

Rib cartilage was harvested first to gain time for carving, observation, and refinement of the grafts. The first layers were taken off the surfaces right away to prepare two balanced blocks. Special feature: The No. 10 blade had to be exchanged for a micro circular saw and a cutting burr because of advanced calcification. Fascia lata was harvested afterward. The defect was symmetrically enlarged as a transverse-oval excision, bilaterally prolonged by short incisions running parallel to the edges of the soft triangles ( Fig. 34.1d ). To minimize tension for later closure, the nasal skin was widely undermined up to the glabella region. Explantation of the graft was easy and the enlarged scarry pocket suitable as a recipient bed for the grafts. A typical columella strut and a meticulously tailored dorsal strut were fitted into the final position and fixed with permanent sutures. The columella strut, length 25 mm, was tightly fixed to the remnant of the septum and the spine area (5–0 monofil) to prevent upward rotation of the tip and shortening of the nasal dorsum. The alar cartilages, so far depressed by the implant, were augmented and fixed to the strut. The dorsal graft, 45 × 11 × 5 mm, concave undersurface and very thin edge on the nasal bone ( Fig. 34.1e, f ), was fixed with multiple fine sutures (7–0 monofil) to the underlay and a strong suture to the columella strut. Dead spaces were obliterated by perichondrium and fascia. The atrophic skin was reinforced by a single layer of fascia lata and a double layer above the new tip ( Fig. 34.1g ). The former defect could be closed with some additional excision and little tension. The spider veins were obliterated by cauterization.

Healing was disturbed by a small necrosis at the tip, progressing to the diameter of the old defect within 10 days ( Fig. 34.1h, i ). Formation of delicate granulation tissue on the edges could not prevent central necrosis of the two-layered fascia and exposure of rib cartilage after 5 weeks. At the end of 6 weeks, tissue had recovered and the defect slightly contracted. Decision was taken against a forehead flap and in favor of a composite ear graft.

Six weeks postoperatively the edges were freshened and the defect, 5 mm in diameter on the bottom, was closed with a composite ear graft, diameter of the skin when harvested 7 mm ( Fig. 34.1j–l ). Healing process went well; the early and late result was good ( Fig. 34.1m, n ).

Psychology, Motivations, Personal Background

An open nasal trauma of the 4-year-old girl could not be treated adequately shortly before the end of the Second World War. The adolescent girl suffered from a severely underprojected profile and a groove in the midline. Being 17 years old, she was offered a modern plastic implant at a university clinic—a “method with no alternative,” as she was told. The result was much appreciated by the patient, family, and friends. The actual shape with the rib grafts is viewed as being more harmonic, more natural, and less “pinched” compared with the shape as it appeared for decades with the implant.

Discussion

In most of our cases, replacement of implants by rib cartilage with reinforcement of the skin and primary closure is possible. In this case, a slight elongation of the dorsum may have been too ambitious even though tension of the skin was low during primary closure. A skin graft for secondary repair might have been sufficient some weeks earlier with the fascia still intact. Such a graft (e.g., taken from the glabella region) would have led to a better color match and probably to a better contour.

Introduction

This 27-year-old woman presented with severe saddle nose deformity. Granulomatosis with polyangiitis (GPA; Wegener granulomatosis) had been verified only 2 years ago even though typical symptoms had occurred already at the age of 17: severe inflammations of the left middle ear and the nasal septum. Slow formation of a saddle nose soon became noticeable while three tympanoplasties were performed in rapid succession. Augmentation of the nasal dorsum with bank cartilage by closed approach had been tried elsewhere at the age of 24. A revision 1 year later by the same surgeon did not improve the result ( Fig. 34.2a, b ). We had to wait 5 years for complete remission and yet another year for stable remission and performed the reconstructive rhinoplasty at the age of 33 (operation by Joachim Quetz).

Diagnosis

Inspection and palpation showed a severe saddle nose deformity with a prominent contour of the inappropriate rib transplant tightly encased by scarred and shrunk skin. Destruction of the nasal spine area and the nasal bone was conspicuous by loss of projection of the midface in the lateral view. Endonasal endoscopy revealed a total loss of septal cartilage manifesting as a subtotal septal perforation. Protection of the deprojected tip felt almost normal. Diagnostic investigation was completed by a lateral cephalographic X-ray ( Fig. 34.2c ), providing good information about soft-tissue relation to the bony midface and a basis for the traditional planning with transparent paper and pencil on a scale of 1:1 ( Fig. 34.2d ).

Surgical Procedure

As in most cases, rib cartilage was harvested first to gain time for carving, observation, reshaping, and refinement of the grafts ( Fig. 34.2h ). The first layers were taken off the surfaces right away for later preparation of two balanced blocks. According to the destroyed spine area and preoperative planning, an unusually long columella strut of ~ 4 cm and a dorsal graft of 5 cm was prepared ( Fig. 34.2i, j ). Perioperative antibiotic prophylaxis and repeated accurate disinfection—basic precautions in patients with increased risks—were performed. An endonasal approach by hemitransfixion incision was used to partly uncover the remnants of the septal cartilage, a narrow falx; to elevate the dorsal skin, strictly avoiding damage to the atrophic inner lining; and to remove the old graft ( Fig. 34.2e ). The columella strut was tentatively inserted into a dissected pocket and caused an extreme saddle of the dorsum and overrotation of the tip by lack of elastic skin ( Fig. 34.2k ). Large-scale undermining of the surrounding facial skin could provide just about a sufficient amount to achieve the aspired profile and projection ( Fig. 34.2l ). A stable gearing between columella strut and spine area and between the grafts was essential to keep up the profile while withstanding significant tension of the skin. The dorsal graft was fixed with a long titanium screw in the area of the former nasal bone for the same reason ( Fig. 34.2f, g ). Closure of the incision was tight and ended up in a small necrosis at the hemitransfixion incision some days later with an exposure of the grafts. Secondary healing under permanent antiseptic occlusive dressing did not work. The defect was finally closed with a vestibulum oris mucosal flap 4 weeks later without further problems. One year later the patient was—unsuccessfully—offered a correction of an alar rim retraction on the right side. This retraction was preexisting but had become more noticeable by the augmentation. The plan was—and still is—to push down the alar rim by a skin cartilage composite ear graft. The graft would be placed into a created vestibular pocket, the cutaneous component facing the nasal vestibule.

Psychology, Motivations, Personal Background

GPA started at the age of 14 years as a limited disease (ear and nose) and progressed some years later, undetected and untreated, to a systemic vasculitis with multi-organ involvement (lymph nodes, kidney, lung, and brain with slight stroke). Her caring family, a sympathetic boss (the patient worked in a barbershop), and a happy marriage helped her to stay mentally stable while experiencing the stigmatizing change in her midface and suffering the long and serious illness. After two rhinoplasties with very limited improvement she was not pushing for the reconstruction. Postoperatively she was pleased but not enthusiastic about the result. The positive reaction of her family, friends, and her clients in the barbershop helped her to fully accept and appreciate her new nose ( Fig. 34.2m, n ). Special feature: Putting on heavy makeup had been her way to cope with formation of the saddle.

Discussion

Complete remission for at least 1 year seems to be an adequate period before repair of a GPA nose. A closed approach was chosen because no work on the tip had to be done and at that time a closed approach seemed to us to be safer in GPA patients with big septal perforation. ² In the meantime, open approaches have proved to be just as safe. Even in patients with steroid medication combined with anti-rheumatic drug therapy we have seen perfect healing processes in most cases. Fixation of the dorsal graft with a Kirschner wire (K-wire) is a good alternative to a titanium screw. Three major issues had to be and were successfully resolved in this case: Mobilization of the surrounding skin, creation of a very strong scaffold, and a semi-rigid fixation by gearing and screwing the scaffold to the damaged bony anatomy to prevent disintegration and dislocation.

Introduction

Initially, this patient had had his paranasal sinuses operated on, followed by four septorhinoplasties elsewhere: removal of a big hump, revision rhinoplasty, second revision for extracorporeal septal reconstruction with polydioxanone foil, and a fourth operation some weeks later following abscess formation—foil and cartilage had to be removed. One year after this last revision and 9 years after the initial sinus surgery the patient, then 37 years old, returned with impaired nasal breathing and deformation of the nose by loss of cartilaginous scaffold to a large extent (operation by Joachim Quetz).

Diagnosis

Inspection showed a deformed nose with an uneven surface, deviation, and loss of projection ( Fig. 34.3a, l ). A contracted scar of the soft triangle on the right side was particularly conspicuous. Palpation revealed a severe lack of protection, whereas rigidity of the thickened skin seemed to contribute significantly to the stability of the whole nose. Endoscopy showed septal deviation to the left and hyperplasia of the lower turbinates. The aim of the upcoming operation was complex restoration of form and function. Reconstruction of the scaffold had to be strong enough to mount and straighten the rigid skin and to withstand later scar contraction.

Surgical Procedure

Building of a new thin septal plate from rib cartilage needs some hours’ time for observation and reshaping to overcome the tendency to warping. For this reason rib cartilage was harvested first and work on the grafts started prior to work on the nose. Curved chips were created by removing the superficial layers off the surfaces with a No. 10 blade ( Fig. 34.3e ). They are carefully preserved and thus provide a useful collection of differently shaped chips for later replacement of the subsurface framework. An open approach was employed for excellent insight and anatomically correct reconstruction of the destroyed and deformed components. Exposure of the remnants of the nasal skeleton and troublesome separation of the septal mucosal sheets were performed with an operating microscope. Only the lateral segments of the upper lateral and the right lower lateral cartilage could be identified ( Fig. 34.3c ). Reconstruction started with replacement of the septum, assembled by two plates, width less than 3 mm ( Fig. 34.3d, f, g ). The bigger plate was tailored to match the dorsal end of the septal defect and to be dovetailed with the spine area ( Fig. 34.3i ). It was fixed to the spine by a drill hole and permanent suture. The upper plate was fitted in the remaining gap; minor deviation of both components was balanced by assembling them directly opposed. They were interconnected by simple interrupted and 8-shaped stitches alternately ( Fig. 34.3d ). Final shape of the new septum was designed and trimmed in situ, dimension of the lower edge resembling an integrated extension graft ( Fig. 34.3c, d, i ). The two plates were bridged by spreader grafts on both sides and thus firmly locked in the desired straight position. ³ The grafts, size ~ 20 × 3 × 2 mm, were tentatively fixed with a fine injection needle and joined with the upper lateral cartilages: four horizontal mattress sutures, following the direction of the injection needle, allowed later shaping of the dorsum without cutting the threads ( Fig. 34.3j ). Finally the whole left and medial part of the right alar cartilage was replaced by choosing suitable elements from the collection of curved chips ( Fig. 34.3k ). The medial crura were fixed to the caudal extension of the neoseptum by permanent mattress sutures and the new tip shaped by modified inter- and transdomal sutures.

Psychology, Motivations, Personal Background

The patient didn′t like to talk about his motivation for the preceding rhinoplasties and his approach to the severe complications. His desire for repair of function and form was easy to follow. In contrast to the evaluation of the surgeon and the good outcome ( Fig. 34.3b, m ), the patient was not entirely pleased with the result.

Discussion

When inner lining and soft-tissue envelope are intact, the anatomically correct reconstruction of the framework with rib cartilage may be the best technique for a superior outcome and a predictable long-term stability. The warping forces of shaped rib grafts can be sufficiently harnessed by the described technique.

Introduction

Five years ago, when the patient was 59 years old, a basal cell carcinoma of the nasal tip and dorsum had been excised and the defect closed by a free skin graft. The patient asked for revision of the poor result (operation by Joachim Quetz).

Diagnosis

Color match was the only positive detail about the skin graft, whereas all other aspects were unsatisfying: Position of the graft was asymmetrical, the subunit principle had been neglected, the shiny atrophic texture did not match the surrounding sebaceous skin, the graft was not in level with the surface, and the contour looked unnatural. Most eye-catching were the resultant misplaced highlights ( Fig. 34.4a, b, j, k ). Aim of the revision was to correct all of these aspects by reshaping the defect by bringing it close to the tip subunit ( Fig. 34.4c ), rearranging the alar cartilages, and replacing the skin with a two-stage forehead flap.

Surgical Procedure

The skin graft was excised and the defect symmetrically enlarged, bringing it as close as possible to the shape of the tip subunit ( Fig. 34.4e ). Skin of the nasal dorsum was completely undermined and gently pulled down to make the defect smaller, thus bringing it closer to the desired shape ( Fig. 34.4c, d ). The skin was fixed in the new position, taking care not to rotate the tip upward. The intermediate and lateral portions of the alar cartilages were found on a level with the top edge of the septum. They were repositioned and reshaped by inter- and transdomal sutures. A foil of a suture pack was used to accurately cut and mold a template representing a three-dimensional copy of the defect ( Fig. 34.4f ). The foil was flattened to two dimensions and transferred to the forehead, turning it upside down. Length and size of the pedicle were defined and marked with ink along with the outline of the template. Base of the pedicle measured 13 mm and was positioned on the right side. The flap was elevated and transposed to resurface the defect. The last steps were performed with a surgical microscope. Excess subcutaneous fat was excised within the distal half of the flap, preserving axial dermal vessels as far as possible. It was inserted in its final position with 5–0 subcutaneous sutures and the skin closed with 7–0 nylon simple interrupted and running sutures ( Fig. 34.4g–i ). For closure of the donor site, the adjacent forehead and scalp tissue was widely elevated and fixed under moderate tension with subcutaneous sutures and a running suture of the skin by 7–0 nylon. The area that would have required more than moderate tension was only approached with resorbable threads and the dog ear excised at the upper end. Granulation tissue filled up the missing volume in the following weeks under permanent semi-occlusive dressing. Three weeks later the pedicle was transacted, the proximal end reduced to a small triangle and reintegrated resembling the “frown lines” of the opposite side. The distal end was meticulously thinned, trimmed, integrated into the defect, and fixed with 7–0 nylon simple interrupted sutures. Waste skin from the middle portion of the pedicle was thinned and used as a free transplant to close off the remaining defect of the forehead now in line with the adjacent skin.

Psychology, Motivations, Personal Background

The patient had never been satisfied with the result, and the surgeon had not been either. As a private person and a tourist guide she always had replied with wisecracks when people commented on her nose. She had been determined to live with this defect. But one day her grandson refused to be collected from school by his grandmother because his classmates had been joking about the “fingernail” on his granny′s nose. That was the moment when she changed her mind and desperately wanted a revision. She was happy with the result and repeatedly remarked that “a new nose is like a new life” ( Fig. 34.4j–m ).