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Animations
Correction of the Typical Features of Cocaine Nose Animation 15.1
Corrective Surgery on Another Patient with Significant Nasal Deformity Related to Cocaine Use Animation 15.2
Pearls
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Caustic effects of insufflated cocaine can destroy layers of the septum and the nasal wall.
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The number one criterion for successful correction of cocaine nose deformity is evidence of a patient’s commitment to abandon cocaine use. This should be confirmed by an independent, qualified specialist.
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The former cocaine user has to have been clean for at least 3 years before surgery is considered.
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The common features of the cocaine nose include foreshortening, an inverted V deformity, deviation at various levels of the nose commonly towards the nostril that is used for insufflation, collapse of the dorsum with saddle nose deformity, retraction of the columella, a pseudohump, widening of the nose, deviation of the columella to the affected side, and notched and retracted ala with concavity.
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Internal examination of the nose commonly demonstrates complete or incomplete destruction of the cartilaginous septum.
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Presence of active rhinitis contraindicates any surgical intervention and may raise suspicion of continued use of cocaine.
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If the alar rim is retracted more than 2 mm, the initial open rhinoplasty incision should include a V-Y advancement incision of the vestibular lining.
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While dissecting the dorsum, every effort should be made to avoid any tears in the dorsal lining that may join the nasal cavity with the dorsal space. Any inadvertent tears should be repaired and made watertight immediately.
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If K wires are used to fix the cartilage to the underlying nasal bone, it is important to avoid penetration of the nasal lining with the end of the K wire, which otherwise can seed bacteria within the cartilage at the time of retrieval of the wire.
In 1912, Owens first reported on the effects of cocaine on the nasal mucosa. Recreational use of cocaine has been rising in the USA and the nose is the most common route for ingestion. The intense vasoconstriction of the nasal mucosa resulting from insufflation of cocaine causes an array of caustic effects with varying degrees of damage to the nasal lining. The additive nature of the insult may ultimately result in complete necrosis of all layers of the septum and nasal wall. As the necrosis deepens, an infection may superimpose and cause additional loss of soft tissues and cartilage. With further use of cocaine, the perforation expands and often results in collapse of the dorsum, retraction of the ala, and foreshortening of the nose.
Some propose the use of microvascular techniques for repair of the perforated septum. However, in the author’s view, this type of heroic measure, which may in fact constrict the airway due to the bulk of the flap, may not be necessary in most patients.
Patient Assessment
Prudent care of the patient with this deformity begins with an in-depth evaluation of the patient’s frame of mind. The number one criterion for successful correction of a cocaine nose deformity is evidence of the patient’s commitment to abandon cocaine use, which should be confirmed by an independent qualified specialist. Otherwise, the gratifying result that is attained can easily be destroyed by insufflation of additional cocaine. This lifestyle change should have lasted for at least 3 years before surgery is considered.
The magnitude of the nose deformity should not distract the examiner and result in focusing on the nose only. It is still crucial to pay attention to the entire face rather than concentrating only on the nose. The surrounding structures and even the distant facial features should be assessed, as in primary and secondary rhinoplasty patients, prior to focusing on the nose. One important adjacent structure to examine is the maxilla.
The magnitude of the nasal deformity varies from patient to patient. There could be a small perforation in the septum with no reflection on the external appearance of the nose. However, those who seek the assistance of a plastic surgeon often demonstrate extensive nasal deformity. The common features of cocaine nose include foreshortening, an inverted V deformity and deviation at various levels of the nose structures. The deviation is largely related to the substantial destruction and necrosis within the insufflation tract. For a right-handed person, this is usually the right side of the nose. Because of the loss of alar support, the nasal tip is pulled to the affected side. Collapse of the dorsum results in a saddle-nose deformity and foreshortening with over-rotation of the tip. Loss of the septum may result in retraction of the columella. In this scenario, the entire nose will become shorter, rather than the tip simply rotating cephalically. The dorsal collapse also results in a hump that was not there previously. This is often the consequence of a posterior shift of the dorsal soft tissues while the bony frame remains intact and protrudes anteriorly in relation to the rest of the dorsum. Additionally, the collapse of the dorsum results in a lateral distribution of the soft tissues and widening of the nose and the alar base. Nasal tip projection is commonly reduced because of the loss of the support ordinarily provided by the anterocaudal septum. The nose appears significantly distorted on the basilar view. The columella deviates to the affected side, which results in a misaligned tip structure. The ala becomes notched and concave on the affected side and often the alar base is malpositioned.
Internal examination of the nose commonly demonstrates complete or near-complete destruction of the cartilaginous septum and a varying degree of rhinitis. Presence of active rhinitis contraindicates any surgical intervention. Such patients should be treated vigorously with systemic antibiotics and topical mupirocin until the rhinitis subsides completely. The presence of rhinitis should also lead one to question whether the patient has indeed ceased using cocaine. The turbinates are commonly enlarged.
Surgical Technique
Since a variety of grafts will be required for this surgery, it is prudent to perform the surgery under general anesthesia. The nose is infiltrated with local anesthetic and vasoconstrictive solution as discussed in Chapter 4 . Because of the significant scarring, infiltration of these solutions may prove difficult.
Although this deformity can also be corrected through a closed rhinoplasty, Far greater precision will be achieved with an external approach. A step or V incision is made in the columella and extended to the ala. If the alar notching is greater than 2 mm, it is advisable to plan a V–Y advancement, as described in Chapter 11 . Otherwise, if an incision is made in the rim and it then becomes advisable to do a V–Y advancement, it will be impossible. If the V–Y advancement is part of the surgical plan, the columella incision is extended towards the intercartilagenous area in a V shape and brought back towards the alar base on the affected side. On the contralateral side, the V–Y advancement is often not necessary, since there is not much retraction of the ala.
The incision is deepened and a skin flap is elevated. After the lower lateral cartilages are exposed, the dissection is continued towards the nasal bones. This is where care has to be practiced to maintain the integrity of the nasal roof lining and to keep the dorsal space isolated from the nasal cavity to reduce the risk of postoperative infection. The existing components must be separated from each other and the soft tissues elongated as far as possible, all the while maintaining the integrity of the nasal lining. A varying degree of difficulty can be encountered during the separation of the soft tissues. Any inadvertent tears in the lining should be repaired and made watertight. As the nasal bone area is reached, the dissection will continue in the subperiosteal plane. The importance of protecting the nasal lining cannot be overstressed. Each time the soft tissues are released, the basal unit (tip and columella) is repositioned caudally to check whether there is enough freedom in the soft tissues to allow for replacement of the missing frame pieces and elongation of the nose. Otherwise, the dissection is continued until the soft tissues are released sufficiently. If the dorsal lining becomes the limiting factor, one can dissect under the nasal bones and release the soft tissues cephalically to gain more length. This seldom becomes necessary, but if it does, it is important to eliminate any communication between the nasal cavity and the dorsum by suturing the nasal lining to the nasal bones after advancement using 5-0 poliglecaprone sutures. It may become necessary to make small burr holes in the nasal bones to pass the poliglecaprone suture to reattach the advanced nasal roof lining to the bone and create a watertight separation of the nasal cavity from the surgical site on the dorsum. If there is a dorsal hump, it is removed with a rasp and osteotomy of the nasal bone is only performed if necessary. The wound is irrigated copiously with saline solution containing 1 g of a first-generation cephalosporin in 1000 ml of the irrigation solution.
A costal cartilage is harvested next. This is discussed in detail in Chapter 19 . If the nose skin is very thin, the perichondrium is harvested and applied as a soft tissue graft. If necessary, a piece of conchal cartilage graft is harvested as described previously for tip reconstruction. A dorsal graft is then carved, adhering to Gibson’s principles. The tongue-and-groove technique is used to achieve an optimal length in patients who do not need significant dorsal augmentation, as described in Chapter 8 . This technique can be used only if there is a residual dorsal septal bar. The dorsum is augmented with a costal cartilage graft wherever there is a deficit. The graft is prepared in a keel shape, tapered laterally, and should be narrower cephalically and caudally. The caudal and cephalic profiles are lower than the central portion of the dorsum. To reduce the potential for warping, a threaded Kirschner wire is passed longitudinally through the fabricated dorsal cartilage graft, as described by Gunter. This technique is not necessary on every patient. It is only used on grafts that seem to have a tendency to warp while on the operating room table. The domes are pulled anteriorly and a columella strut is placed in position and tattooed across using a 25 gauge needle to assist in proper alignment of the medial crura and columella strut while suturing the graft in position, as described in Chapter 4 (see Video 4.20biii). The columella strut is fixed to the medial crura in at least two places using 5-0 PDS sutures. The dorsal graft is placed in position and the caudal end is notched to accommodate the columella strut and fixed to it using 5-0 PDS or 5-0 nylon if there is no residual dorsal septal cartilage to utilize the tongue-and-groove technique. The columella strut should extend beyond the anterior limits of the dorsal graft to aid in the creation of an optimal supratip break. The dorsal graft is either sutured in position or fixed to the underlying bones using two temporary K wires. It is crucial to make sure that these K wires do not penetrate the nasal lining. The cartilage graft can also be fixed in position using a microscrew. The base of the columella strut is fixed to the anterior nasal spine using a 5-0 nylon or PDS suture. It is important to realize that it is not necessary to use both the tongue-and-groove technique and a dorsal conchal cartilage graft. If there is no need for the dorsal augmentation, and there is a residual dorsal bar of the septum, the tongue-and-groove technique is employed, as indicated above.
The alar cartilage is seldom completely destroyed. If the entire lateral crus is missing, it is replaced using a thin layer of costal cartilage harvested from the surface of the rib cartilage. Maxillary grafts are used if necessary to reconstruct the lateral and the premaxillary area. However, this is also rarely necessary. The position and direction of the dorsal graft is checked repeatedly to ensure proper alignment with the rest of the facial structures. If a tip graft is deemed necessary, it is preferably obtained from the conchal cartilage rather than the costal cartilage, since the latter is often too harsh for this purpose. The tip punch is used to harvest the graft and it is fixed in position using 6-0 polyglactin, as described in Chapter 7 and Chapter 19 . The position of the graft is checked three-dimensionally to ensure optimal symmetry. If V–Y advancement is one of the surgical goals, the V flap that was raised initially on the affected ala is dissected completely to the rim and reflected caudally, like an open page of a book. The V–Y advancement is accomplished, the Y portion is repaired first and then the flap is advanced caudally. Prior to the closure of the flap, an alar rim graft is applied to ensure proper stability. Simple stents are applied to the medial and lateral surfaces of the ala and are fixed in position using a 5-0 polypropylene through-and-through stitch. The columellar incision is then repaired using 6-0 fast absorbable catgut. An Aquaplast™ and a metal dorsal splint are applied if an osteotomy has been performed. Otherwise, SteriStrips would be sufficient. The external K wires are usually removed in 3 weeks.
While challenging, this surgery is the most gratifying type of rhinoplasty. If patients are selected properly and remain cocaine-free, this surgery can change their quality of life tremendously and erase the stigma of their previous poor judgment ( Figures 15.1, 15.2 ; Animation 15.1; Animation 15.2; Boxes 15.1, 15.2 ).
