Pediatric Rhinoplasty
Dirk Jan Menger
INTRODUCTION
Pediatric rhinoplasty remains a topic of controversy as the cartilaginous nasal septum is a dominant growth center of the nose. This concern arises from surgical interventions impairing the outgrowth of the nasal skeleton, leading to facial underdevelopment and progressive malformations. Specifically, resection or detachment of specific cartilaginous structures of the nasal skeleton carries the risk of growth disturbances of both the nose and maxilla. Therefore, rhinoplasty in children is fundamentally different from rhinoplasty in adults.
During the last decade, recommended techniques have become more conservative, with emphasis in tissue reorientation and augmentation rather than resection and reduction. In children, both external and endonasal approaches can be used to reallocate or reconstruct the nasal skeleton after trauma, infection, or in congenital deformities. Alternatively, these approaches can be used as a route to remove malignant or benign pathology.
Anatomy and Development of the Growing Nose
The nose of a baby is much smaller compared to an adult as it has a short nasal dorsum, less projection of the nasal tip and columella, rounder nostrils, and a large nasolabial angle. The overlying soft tissue envelope has a thick layer of subcutaneous adipose tissue, and the nasal skeleton of a newborn is mainly cartilaginous. The nasal septum initially develops due to the formation of new cartilage, but within the first postnatal year, an endochondral ossification process starts in the region of the anterior skull base. This is the beginning of the formation of the perpendicular plate. At a later stage, the perpendicular plate extends due to progressive ossification of nasal septal cartilage. Due to this ossification, most of the cartilaginous part of the nasal septum loses contact with the sphenoid. In adults, only a small remnant of septal cartilage, the so-called “sphenoid tail,” can be found between the cartilaginous nasal septum and the sphenoid. It separates the perpendicular plate from the vomer. The formation of the vomer is the result of extracartilaginous ossification.
In females, nasal growth is completed earlier (16 to 18 years) than in males (18 to 20 years). There are two significant periods of nasal growth: during the first 2 years of life and puberty. The typical “baby face” disappears due to the more rapid and longer-lasting development of the nose, maxilla, and mandible in relation to the neurocranium. The cartilaginous nasal septum plays a crucial role in both nasal and midfacial growth. The nasal septum has two thicker areas with different mitotic activity and histologic maturation. These growth zones have a transverse diameter of approximately 3 mm, whereas the surrounding thinner cartilage is 0.4-mm thick. Both zones extend from the sphenoid. The “sphenodorsal” zone is located between the sphenoid and the nasal dorsum and appears to be primarily responsible for the normal increase in length and height of the nasal dorsum. The “sphenospinal” zone is located between the sphenoid and the anterior nasal spine and is the driving force in forward outgrowth of the premaxilla region. Experimental studies and clinical observations have shown that destruction of these zones during childhood result in underdevelopment of both the nose and the maxilla. The effect of destruction is age related with younger children developing more severe malformation compared to their older counterparts. A young child with complete destruction of the nasal septum will clinically appear
with an underdeveloped nose displaying a saddle deformity, columellar retraction, overrotation of the nasal tip, and a retroposition of the midface. Destruction of these zones can be the result of trauma, nasal septal hematoma, or abscess. However, it is the dedicated interventions of the well-meaning surgeon that remain the primary concern. The goal of this chapter is to review the indications and goals for pediatric rhinoplasty and surgical guidelines to avoid growth disturbances and postoperative sequelae.
with an underdeveloped nose displaying a saddle deformity, columellar retraction, overrotation of the nasal tip, and a retroposition of the midface. Destruction of these zones can be the result of trauma, nasal septal hematoma, or abscess. However, it is the dedicated interventions of the well-meaning surgeon that remain the primary concern. The goal of this chapter is to review the indications and goals for pediatric rhinoplasty and surgical guidelines to avoid growth disturbances and postoperative sequelae.
HISTORY
Rhinoplasty in children may be indicated due to trauma, infections, congenital features, or psychological or functional problems. Therefore, history and examination should be focused on the specific clinical picture. An accurate history and physical examination are mandatory for correct diagnosis and treatment; therefore, a good relationship with parents and child is essential. Esthetics and function should be evaluated separately. How does the nose look like on the outside? Does it cause problems, distress, or anxiety at school or in relation with other children or adults? Does the child breath well? How is the right side compared with the left side? Is it blocked continuously or intermittently? Does the impairment of nasal breathing interfere with the child’s daily activities? Specifically in children, the age and length of the child are important and the question whether further outgrowth of the nose is to be expected. The medical history should also include the use of medication and any medication that can influence blood coagulation should be stopped prior to surgery.
PHYSICAL EXAMINATION
A standardized rhinoplasty protocol is essential for a successful outcome. This includes standardized preoperative documentation using an assessment and surgical rhinoplasty sheet. In most children, evaluation of the nasal airway can be performed using a headlight and a small nasal speculum. What is the condition of the nasal septum: is it in the midline or deviated? Does the septum provide sufficient support to the upper lateral cartilages and nasal tip? Is the external and internal nasal valve region open or blocked? Does the lateral side wall collapse during forced inspiration? What is the condition of the mucosa? Inhalation allergies should be tested in selected cases and when required treated with antihistamine and nasal corticosteroids. Is there evidence of nasal polyps or other mucosal abnormalities? Does the child have hypertrophy of the adenoids? Inspection of the nasal cavity and nasopharynx using an endoscope is essential in selected cases. Examination under general anesthesia might be required in some cases of recent trauma, hematoma, or abscess of the nasal septum or dorsum (Fig. 22.1). Standardized preoperative rhinoplasty photographs (frontal, oblique, lateral, basal and bird view) should always be performed and documented. Sometimes 3-D imaging or computer-simulated imaging might be helpful in the communication with the patient. Imaging, like magnetic resonance imaging (MRI) of the anterior skull base, is essential in the preoperative assessment of dermoid cysts. In all cases, a written informed consent with all possible side effects of the surgery and postoperative period should be given and signed by the patient’s parents.
INDICATIONS
The goal of rhinoplasty in children is to restore the anatomy and function or to promote normal development and outgrowth of the nose. For every indication, the expected benefits of intervention should be weighed against the possible adverse outcomes on nasal and midfacial growth. Ideally, surgery should be postponed until after the pubertal growth spurt. However, there are distinct indications for immediate intervention. Apart from tumors like malignancies, these indications include destruction of the nasal skeleton due to nasal septal abscess or severe nasal trauma. In these cases, the skeleton should be reconstructed in order to avoid inhibition of growth due to
destruction of the nasal septal growth centers. Other indications for immediate surgical intervention are severely impaired nasal breathing and nasal deformity causing psychological problems. A nasal deformity presents a serious psychosocial challenge to children; they have to cope with an appearance that is different that cannot be concealed and is subject to social stigma. The increasing use of facial plastic surgery in a culture that is focused on appearance heightens the pressure on those who look different. Patients with facial disfigurement or severe nasal deformities often report increased social anxiety, feelings of low self-esteem and self-worth, and depression. The degree of deformity, however, does not show a linear correlation with the degree of experienced distress. From a psychological point of view, similar to, for example, otoplasty, the ideal timing of surgery is at preschool ages in which children do not note the deformity. The decision to perform rhinoplasty, however, depends on the degree of the deformity, the psychological effect on the child, and the impact on nasal growth and development.
destruction of the nasal septal growth centers. Other indications for immediate surgical intervention are severely impaired nasal breathing and nasal deformity causing psychological problems. A nasal deformity presents a serious psychosocial challenge to children; they have to cope with an appearance that is different that cannot be concealed and is subject to social stigma. The increasing use of facial plastic surgery in a culture that is focused on appearance heightens the pressure on those who look different. Patients with facial disfigurement or severe nasal deformities often report increased social anxiety, feelings of low self-esteem and self-worth, and depression. The degree of deformity, however, does not show a linear correlation with the degree of experienced distress. From a psychological point of view, similar to, for example, otoplasty, the ideal timing of surgery is at preschool ages in which children do not note the deformity. The decision to perform rhinoplasty, however, depends on the degree of the deformity, the psychological effect on the child, and the impact on nasal growth and development.
 FIGURE 22.1 Nasal septal hematoma. Note the swollen septum in the right and left nasal vestibule, 1 week after nasal trauma. |
CONTRAINDICATIONS
In general, rhinoplasty for esthetic features without functional or psychological complaints should be avoided in children. There are two reasons for this. First, as mentioned before, surgery can induce disturbances of the normal development and outgrowth of the nasal skeleton. For example, resection of a basal strip (sphenospinal zone) from the nasal septum will disturb the development of the anterior nasal spine and the maxilla. For example, separating the upper lateral cartilages from the nasal septum before the puberty growth spurt can induce a hump-like deformity as the septum will grow anterior the upper lateral cartilage. Secondly, children are not yet able to decide emotionally whether a certain physical condition, for example, a minor hump deformation, should be corrected surgically or not. Special attention should be focused on parents who try to advocate and persuade the surgeon to perform surgery on their child. These parents believe that they support their child by exaggerating functional and psychological complaints accompanying the esthetic deformation. In those cases, it is important to educate and explain to the parents and the child how the nose develops and grows and what sequels can occur postoperatively when rhinoplasty is carried out before full maturation of the nose and mid-face. Sometimes, it is to be advocated to evaluate the condition at certain regular intervals like 12 months. If the functional, esthetic, or psychological situation changes, surgical intervention might be reconsidered.
PREOPERATIVE PLANNING
Patients and parents should be informed that long-term results cannot be predicted and the need for revision surgery at a later stage should be discussed. For this reason, both patient and parents should also be informed about continuing follow-up until after the adolescent growth spurt. Similar to rhinoplasty in adults, standardized preoperative and postoperative photography should be performed. A standardized assessment and operation form are recommended for meticulous assessment and documentation of the preoperative anatomical condition and the clinical findings during surgery. The risk of inhibition of nasal growth and development is lower when surgical technique conforms to the following guidelines for rhinoplasty in the pediatric age group.
SURGICAL TECHNIQUE
The child is brought into slight reverse Trendelenburg position as this position reduces bleeding. Surgery is usually performed under general anesthesia in combination with a local infiltration anesthetic and topical application of cocaine in order to promote vasoconstriction and to prevent bleeding. The local anesthetic should be given at least 10 minutes before starting surgery.
Guidelines for Pediatric Rhinoplasty
Based on clinical observations, experimental data of surgical procedures, and knowledge of the anatomical development of the nose, “conservative” guidelines can be given in order to avoid disturbances of the normal outgrowth and development of the nose.
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