Cosmetic Rhinoplasty
Summary
Cosmetic rhinoplasty is still one of the most frequently performed facial plastic procedures and probably the most challenging one. Reductive techniques have been replaced by techniques that emphasize remodeling, restructuring, and reinforcing existing structures of the nose with very little resection of tissue. Surgeons today must focus on obtaining noses that are well balanced with the patient′s face, that fulfill the patient′s desires and expectations, and that retain the patient′s ethnic features.
Introduction
Cosmetic rhinoplasty is one of the most challenging operations a facial plastic surgeon can perform. The surgery has evolved over the years, and reductive surgery, in which a lot of tissue is resected, has been replaced by procedures that emphasize restructuring and strengthening the existing anatomical findings. A successful rhinoplasty will depend on whether the surgeon has a clear understanding of what the patient′s desires are, has been able to make a correct anatomical diagnosis, is able to offer the patient realistic expectations, and has the training and expertise to be able to make things happen. Today surgeons must focus on long-term results that look balanced and on noses that are in harmony with the rest of the face.
Approach to the Nasal Septum/Graft Harvesting
Most rhinoplasties will need different amounts of grafting material. Cartilage for grafting can be harvested from many places, the most common being the nasal septum and the auricular concha. In extreme cases where large amounts of cartilage will be needed or in the cartilage-depleted patient, cartilage can be harvested from the rib.
Septal cartilage is the grafting material that is most commonly used in rhinoplasty. It is easy to harvest, has a very low morbidity rate, is easy to carve, and offers excellent long-term results. The downside is that quantities are limited, and in revision cases very little is left to harvest. Septal cartilage is especially useful for structural grafts like struts, spreader grafts, dorsal augmentation grafts, and septal extension grafts. This cartilage is ideal to morcelize and use to fill in depressions or hide irregularities. Septoplasty can be performed through several incisions: a hemitransfixion incision, a Killian incision, or through the same open approach by dividing the medial crura. Cartilage is harvested depending on the patient′s needs, always taking care to leave at least 1 to 1.5 cm of cartilage in the form of an inverted L caudally and dorsally ( Fig. 24.1 ). This will prevent collapse of the support structures of the nose. Any septal deviations should be corrected. If there is a need to perform turbinate surgery or functional endoscopic surgery of the paranasal sinuses, this is performed prior to management of the septum. Septal mucosa is sutured with a continuous 5–0 mattress absorbable suture.
If the septum does not have enough cartilage for grafting, this can be obtained from the auricular concha. Auricular cartilage can be harvested using an anterior or posterior approach, taking special care not to tear the cartilage and performing careful hemostasis of underlying structures. Skin is sutured with 5–0 Prolene, and conchal packing with gauze impregnated with antibiotic ointment is secured by a single through-and-through mattress suture to help prevent the formation of hematoma, possible skin necrosis, or deformity of the ear. Auricular cartilage is especially useful in the nasal tip because of its concave shape. Alar batten grafts, tip grafts, and even dorsal onlay grafts can be used with good results ( Fig. 24.2 ).1,2
Approaches in Rhinoplasty
Rhinoplasty is not an easy operation, and proof of this is the variety of approaches that exist to perform this operation. There are three basic surgical approaches that can be used in rhinoplasty and that provide the surgeon with the necessary surgical exposure to perform the surgery:
Nondelivery
Delivery
External
All of these approaches use different types of incisions, which are the way of accessing the different nasal structures.3,4
Note
Nondelivery approach:
Cartilage-splitting incisions: transcartilaginous, intercartilaginous
Delivery approach:
Marginal incision + intercartilaginous incision
External approach:
Transcolumellar incision + marginal incision
Incisions are done using a no. 15 blade. Tissue is retracted with a two-prong retractor that is held in the nondominant hand.
Nondelivery Approach
The nondelivery approach is a technique used when very small changes are needed on the nasal tip or when limited dorsal work is going to be performed. The transcartilaginous incision is used basically to resect the cephalic portion of the lateral crus. The caudal and cephalic margins of the alar cartilage should be clearly identified. An incision is made at least 5 mm cephalic to the caudal margin of the lateral portion of the alar cartilage. The vestibular skin is dissected cephalically, and the cephalic portion of the lateral crura of the alar cartilage is incised and removed after careful dissection in the subperichondrial plane. Ideally, an intact strip of at least 7 to 8 mm of alar cartilage in its lateral portion should be left behind. The same procedure is performed on the contralateral side, taking care to leave the same amount of cartilage on both sides. The vestibular skin incision is closed with 5–0 absorbable suture material ( Fig. 24.3a ).
Note
Indications for a nondelivery approach: small supratip fullness and small cephalic rotation of the nasal tip.
Delivery Approach
The delivery approach is indicated when bigger modifications are going to be performed on the nasal tip.
Note
Indication for a delivery approach: bigger modifications on the nasal tip.
Many surgeons use this approach not only to modify the tip but also to create changes on the nasal dorsum. Two incisions are used to deliver the nasal tip: the marginal incision and the intercartilaginous incision. Through this last incision, the nasal dorsum can also be dissected.
The intercartilaginous incision is placed in the area between the caudal margin of the upper lateral cartilages and the cephalic margin of the alar cartilages ( Fig. 24.3b ). The incision should follow the anterior septal angle, following the caudal edge of the nasal septum.
Tips and Tricks
Care should be taken to make sure the incision is placed caudal to the internal nasal valve to avoid scarring in this area.
The marginal incisions can be connected in the midline at the level of the anterior septal angle and the upper portion of the caudal edge of the septum to expose the upper two-thirds of the nose.
The marginal incision is placed following the caudal margin of the alar cartilage. It is not a rim incision.
Tips and Tricks
Two helpful hints can be used to keep the incision in the proper area: laterally, the caudal margin of the alar cartilage lies in a non-hair-bearing area, and its edge can be palpated with the handle of the scalpel. Care must be taken not to damage the dome area. The middle finger of the nondominant hand can be used to expose the alar cartilages properly.
Medially, the dissection is completed after the dome area and the intermediate crus are dissected free of the overlying soft tissue. Once the dissection is completed, the alar cartilages can be delivered and structures modified ( Fig. 24.4 ).
Caution
When delivering the nasal tip structures, care must be taken not to dissect the alar cartilages too far laterally or medially.
External Approach
The external rhinoplasty approach provides the surgeon with the best exposure of the tip, the middle cartilaginous nasal vault, and the bony dorsum (see Video 30, The Crooked Nose, and Video 31, The Up-rotated Tip, Revision Surgery ). With this technique, the surgeon is able to diagnose accurately any presence of deformities or asymmetries and is also able to perform in a more precise manner resections and placement of sutures and grafts.5
Note
Indications for an external approach:
Important asymmetries or deformities of alar or upper lateral cartilages
Nasal tips that have poor structural support (poor projection, poor rotation)
Deviated nose
Long overprojected nose
Presence of congenital or acquired deformities: saddle nose, septal perforations, cleft lip noses
Elderly patients
Revision rhinoplasty
Transcolumellar Incision/Elevation of the Flap
The transcolumellar incision is marked as an inverted V at the level of the midcolumella. The lower margin of the incision is placed above the feet of the medial crura to give support to the final scar ( Fig. 24.5 ). This incision is connected to bilateral marginal incisions that are placed no more than 2 mm behind the caudal margin of the medial crura and follow the caudal margin of the entire alar cartilage laterally. The incision can be performed with a no. 15 or a no. 11 blade, taking care to keep the blade perpendicular to the skin, not to bevel skin edges, and keeping the incision superficial to avoid damage to the medial crura.
Flap elevation is performed with angled Converse or Walter scissors that are placed below the musculoaponeurotic layer of skin that covers the medial crura and directly above the cartilage. Clean cuts are made with the scissors completing the midcolumellar incision. The flap is retracted upward using small double-prong skin hooks. If the columellar arteries are seen, they are cut and if necessary cauterized. Dissection of the flap is continued upward and laterally using skin hooks and keeping as close as possible to the cartilage structures of the nasal tip. If the proper plane of dissection is achieved, it is a relatively avascular approach, and only a thin perichondrial layer is left covering the cartilage.
After the skin muscle flap has been elevated offthe lateral crura, the dissection is shifted to the midline, the anterior septal angle is identified, and dissection is continued over the cartilaginous nasal vault. Once the correct cartilaginous plane has been identified, the areolar tissue found here can easily be dissected in a blunt fashion with a cotton-tip applicator all the way up to the rhinion ( Fig. 24.6 ).
Management of the Upper Third of the Nose: The Bony Nasal Vault
The bony nasal vault can be accessed through the endonasal or external approach. If accessed endonasally, the two intercartilaginous incisions are connected by a partial or complete transfixion incision just anterior to the caudal edge of the nasal septum. The plane of dissection over the dorsum is done under direct vision using an Aufricht or Converse retractor. It should be directly above the perichondrium of the upper lateral cartilage in the middle nasal vault and below the periosteum over the bony vault. Care must be taken not to dissect too far laterally. Incision of the periosteum should be performed 2 mm above the caudal end of the nasal bones with a no. 15 blade, and elevation is completed with a Joseph dissector, taking care not to undermine too far laterally over the nasal bones. The basic surgical techniques performed on the upper third of the nose are hump reduction and osteotomies.
Hump Reduction
A bony nasal hump can be removed with an osteotome or a rasp, depending on the preference of the surgeon. Usually osteotomes are used for big humps and rasps for smaller deformities. Generally, the bony part of the hump is much smaller than the cartilaginous part.
The cartilaginous portion is lowered first beginning at the osseocartilaginous junction and then following the resection caudally toward the anterior septal angle. The cartilaginous dorsum is incised using a no. 15 or no. 11 blade transecting the dorsum evenly on both sides. Ideally, the incised cartilaginous dorsum should be left attached to the bony dorsum because this will help when the osteotome is placed for hump removal. An adequate hump resection should extend into the nasofrontal angle. Several points should be kept in mind:
The skin is thick over the nasofrontal angle and the supratip region and thin over the rhinion and the domes ( Fig. 24.7 ).
Diagram showing skin thickness over the nose. It is thick at the nasofrontal angle and supratip area and thin over the domes and rhinion.
If the surgeon wants to achieve a straight dorsum, the highest point should be the osseocartilaginous junction or rhinion, directing the osteotome toward the naso-frontal angle ( Fig. 24.8 ).
Final dorsal refinements are made with a rasp. It should be angled away from the midline to avoid avulsion of the upper lateral cartilage from the undersurface of the nasal bones. Debris is washed away with saline solution.
Any irregularities on the dorsum can be palpated with a finger moistened in hydrogen peroxide or water and sliding it carefully down from the radix to the anterior septal angle.
Osteotomies
Osteotomies are techniques used to modify the shape of the bony nasal dorsum and can be divided into medial, intermediate, and lateral types. They can be performed with 2- to 3-mm guarded or unguarded straight or curved osteotomes. The type of osteotome that is used depends on the preference and expertise of the surgeon.6
Indications for an osteotomy include
To close an open roof deformity, which is usually the result of a dorsal hump excision
To correct a crooked nose
To narrow wide nasal sidewalls
Medial Osteotomies
Indications for a medial osteotomy include
To mobilize lateral sidewalls
To correct a crooked nose
To narrow a wide nose that does not have a hump
This type of osteotomy is not performed routinely. It is usually done using a 2- to 3-mm osteotome that is placed at the junction of the septum with the nasal bone. The osteotome should be angled laterally away from the mid-line, taking care to avoid entering the thick frontal bone ( Fig. 24.9 ).
Intermediate Osteotomies
Intermediate osteotomies are not performed routinely and have special indications:
Extremely wide nasal dorsum that does not have a hump
Deviated nose where the height of one lateral sidewall is much higher than the contralateral side
Crooked nose with convex bones
An intermediate osteotomy should be performed before a lateral osteotomy using a sharp 3-mm osteotome. The osteotomy should be placed somewhere in the midportion of the lateral nasal wall following a path that runs parallel to the path of the lateral osteotomy. It is important not to detach the periosteum or the soft tissue from the bone, as this will help keep the bone fragments in place ( Fig. 24.10 ).
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
