Rhinoplasty is one of the most challenging operations in plastic surgery. The three-dimensional nature of the nose, conformed by skin and soft tissue envelope (S-STE), and the shape and orientation of the nasal cartilages and bones are variables that, when grouped together, confer a nearly limitless number of different configurations seen in nasal appearance. Additionally, each of the constituent parts of the nose are intricately related to one another so that even small change in one component can lead to substantial changes elsewhere, thereby creating a large impact upon the nose. Another obstacle in rhinoplasty is the technical demands that the operation imposes. Nowhere else in plastic surgery is the margin upon which success hinges so slim, that a millimeter can spell the difference between a successful result or disappointment. Finally, manipulation of the form of the nose requires an artistic vision and sense of proportion and dimension. While there may be an aesthetic ideal for other operations, the ideal nose for one face may be completely different for another face, necessitating a keen aesthetic judgment by the surgeon.
Wide variations in technique, philosophies, and surgical results can be seen among rhinoplasty surgeons. Some surgeons use an “ideal nose strategy” for rhinoplasty. These surgeons have a vision of a perfect nose and focus their rhinoplasty efforts toward the creation of this idealized goal for every face. Unfortunately, the “ideal nose strategy” carries some inherent flaws. This strategy assumes that all parts of the nose that do not meet the criteria of this ideal nose need to be changed. The authors contend there is a wide range of features that may be deemed as attractive and must be considered in the context of the remainder of the facial features and nose. Surgeons who ascribe to the ideal nose strategy will often use more extensive radical procedures with extensive grafting in an effort to impart more dramatic changes to the nose. While the surgeon may be able to achieve their goal in changing one aspect of the nose, it often comes at the expense of unintended changes in the remainder of the nose. Another downside with the ideal nose mindset is that it will lead the surgeon to creating an imbalance between the nose and the corresponding facial features. A successful rhinoplasty operation is a marriage between the face and nose so that not only is the appearance of the nose improved but the remainder of the facial features are also enhanced.
Rather than purporting that all noses should appear similar (the ideal nose strategy), the senior author (R.K.) ascribes an approach that attempts to maximize the beauty within each nose. The senior author has developed a philosophy emphasizing a collection of subtle changes to the nose as a means to maximize both its function and natural appearance. A central tenet to this philosophy is to respect the complexities of the nasal anatomy. Each constituent part of the nose is interrelated, whereby seemingly small changes in one part of the nose may create untoward subsequent changes in other parts of the nose. The time factor can add another dimension of complexity where additional changes may manifest within the nose when long-term follow-up is undertaken.
This philosophy is based on 28 years of experience and more than 5000 rhinoplasty patients. The aesthetic goals of the operation are to create subtle, artistic refinements that will continue to improve during the healing continuum. While some surgeons may try to forcibly manipulate each nose to look like an “ideal nose,” the authors contend that soft, subtle changes to the existing nose will lead to a more natural looking nose and harmoniously achieve facial balance. Many of these small changes will continue to improve with time, resulting in further refinement of the nose.
The senior author’s approach to nasal tip definition is classified under the broad category of transcartilaginous techniques , where the lower lateral cartilages are shaped through direct excision and removal of excessive lower lateral cartilage bulk. Traditionally, these techniques have been separated into two categories: retrograde excision of cartilage and direct excision. The transcartilaginous approach offers several distinct advantages. First, this technique is the least disruptive technique available. The only major tip supportive mechanism affected is the relationship between the lower lateral cartilages and the upper lateral cartilages. However, the underlying anatomy of the nose, including the vestibular mucosa, is left for the most part undisrupted, which translates visually into results that maintain the natural features of the nose. While other techniques may leave behind a footprint of a rhinoplasty such as a columellar scar, asymmetry of the alar rim, or loss of the highlights of the soft tissue facets, the transcartilaginous approach we describe provides visual improvements while minimizing the usual surgical stigmata. When properly executed, the integrity of the lower lateral cartilage is preserved, providing a natural shape to the lower lateral cartilage. Over time, further nasal tip refinement is seen as the skin continues to mold.
When a rhinoplasty surgeon decides to perform a particular surgical maneuver, consideration must be given to the serious, aesthetic consequences for the patient. For example, suture techniques can in some instances exacerbate internal recurvature of the lower lateral cartilages, creating potential airway obstruction. Over time, some suture techniques can result in bossae and knuckling or, if improperly executed, can also lead to nostril asymmetry, alar notching, loss of the soft tissue triangle facets, unnatural nasal contours, and alar depressions. Additionally, suture techniques can result in a pinched nasal tip, an obvious surgical stigma.
The transcartilaginous technique has the significant advantage of minimizing soft tissue edema. While the open technique and suture methods will require dissection over the nasal domes, the soft tissue of the nasal tip is left relatively undisturbed while using the transcartilaginous operation. The larger extent of supratip swelling associated with other techniques can lead to an undesired outcome. Many surgeons have attempted to compensate for this additional swelling by overprojecting the nose, making the entire nose larger. Most patients seeking primary rhinoplasty do not want their nose larger but instead are seeking a less extreme version of their existing nose.
One purported disadvantage of the transcartilaginous technique is the steep learning curve associated with it. This technique requires the ability to interpret the underlying lower lateral cartilage anatomy without direct visualization. A combination of visualization, palpation, and judgment are necessary tools to perform this technique. In addition, the surgeon must be able to determine if the amount of cartilage excised was symmetrical and exact in nature. Another obstacle in learning the transcartilaginous approach is the ability to make small changes to control nasal tip projection and rotation. Every surgical technique carries an associated learning curve; the authors believe the transcartilagionous technique significantly limits potential complications compared to other more aggressive techniques.
All patients are evaluated in person by the physician. While the Internet and email are continuing to revolutionize the practice of medicine, electronic photographs cannot replace a thorough intranasal exam and palpation of the lower lateral cartilages and nasal tip support. Anterior rhinoscopy allows for evaluation of the nasal septum and any deflections which may need to be addressed during the operation. Palpation of the anterior portion of the septum can help determine the contribution of the septum to projection and rotation. During the initial consultation, an understanding between the surgeon and patient is necessary to ensure the patient and surgeon have a shared goal of what can be achieved.
Preoperative preparation of the patient plays a significant role in creating the setting of a successful operation. First, preoperative icing is performed on all patients. Ice acts as a natural and powerful vasoconstrictor of the nose, which significantly reduces edema, swelling, and bruising. Low doses of preoperative diazepam and meperidine can help patients relax and thereby release less stress hormones, which can lengthen the recovery process.
Cotton pledgets soaked with 2% tetracaine (Pontocaine) are placed against the intranasal mucosa to locally anesthetize the field. Patients are initially injected with a solution of 0.5% ropivacaine and 1% lidocaine with epinephrine 1 : 200,000 in a 1 : 1 mixture along the soft tissues of the nose and septal mucosa. The authors prefer to mix the epinephrine due to a perceived longer lasting effect intraoperatively and quicker onset of action than that seen when using premixed lidocaine and epinephrine. Care must be taken to ensure avoiding dosing mistakes when mixing these directly. Another common mistake to be avoided is using too much volume with local anesthesia, thereby obscuring the nasal form of the nose.
Addressing the Septum
Initially, a modified hemitransfixion incision is made 5 mm posterior to the membranous septum. The posterior location of the incision conceals visibility of the scar from the lateral view. In addition, the farther posterior location is less likely to disrupt nasal tip support as opposed to a hemitransfixion or full transfixion incision. The septal mucoperichondrium is then retracted with a brown forcep and initially elevated with a Woodson elevator. If cartilage grafting is needed, septal cartilage can be harvested along the nasal floor just above the maxillary crest with a septal knife. Not uncommonly, septal deviations can cause airway obstruction and once removed will improve nasal airflow; these include deflections of the perpendicular plate and septal spurs along the nasal floor.
If manipulation of the anterior septum is required, a retrograde septal mucosal approach can be used with a spreading motion of the gooseneck dissecting scissors. If exposure of the nasal spine or depressor septi muscle is needed, a Parkes retractor can be utilized. Changes in projection and rotation of the nose can be performed by changing the length and shape of the caudal septum. Deprojection of the nose and rotation can be performed by precise resection of a portion of the anterior septal angle. Shaving the caudal septal region will in part lead to slight shortening of the nose, and can help rotate the tip if wedge-shaped portion is excised. Counterrotation can be performed by careful excision of the posterior septal angle.
Addressing the Nasal Tip
The lower lateral cartilages are addressed by a transcartilaginous approach. The surgeon must be able to accurately predict how much cartilage must be excised and how much is left in vivo to achieve the desirable aesthetic outcome and prevent untoward sequelae. A two-pronged retractor is used to retract the nostril, and the forefinger is used to present the lower lateral cartilage into view. An incision is first made through the vestibular mucosa only along the midportion of the lower lateral cartilage, 6 to 9 mm superior from the alar rim.
The vestibular mucosa is bluntly elevated superiorly during the excision, allowing for exposure of the lower lateral cartilage. An incision is then made with a No. 15 blade scalpel on the lower lateral cartilage, outlining the caudal extent to be resected. Gooseneck scissors are used to dissect the soft tissues from the lower lateral cartilage in a supraperichondrial plane to the cephalic edge of the lateral crus. The superior portion of the lower lateral cartilage, including a portion of the lateral, intermediate, and medial lower lateral cartilage, is excised. Once the cartilage has been excised, the lower lateral cartilages are inspected externally and visual changes of the shape of the nasal tip are inspected, preserving an intact strip of lower lateral cartilage ( Figures 8-1 and 8-2 ). The lateral portion of the lower lateral cartilage is preserved, preventing potential alar collapse and unsightly alar pinching. Vestibular skin in this area is treated with the utmost care and is preserved.