Primum non nocere
The first goal during rhinoplasty, as with all other aspects of medicine and surgery, is to do no harm, and it pertains to both nasal function and aesthetics. Moreover, every rhinoplasty patient will present with a set of positive nasal functional or aesthetic features that need be preserved. Capitalizing on years of training and cumulative experience while paying close attention to the patient’s stated concerns, surgeons should prioritize the nasal features to be surgically addressed and, in some ways even more important, those that need to be preserved both functionally and aesthetically.
Paradigms of beauty are somewhat subjective and variable, and may shift gradually with time. Some models considered beautiful today may have not been considered as such in different time periods throughout history. However, timeless concepts such as balance, symmetry, and general guidelines of facial and nasal proportions can help lead us with the certainty and conviction of knowing the surgical goal will be aesthetically pleasing and natural-appearing decades after accomplished.
An ideal surgical result is based on excellent nasal function as well as a proportioned, balanced, natural-appearing, aesthetically pleasing nose. Conceptually, a great rhinoplasty result deemphasizes the nose to allow the casual observer to look past it, focusing on the subject’s eyes, appreciating the entire face in context, without specific distractions. Each rhinoplasty is different, in as much as a person’s nose should befit their gender, ethnicity, and surrounding facial features as well as their underlying facial skeletal structure.
The rhinoplasty surgeon’s mindset should be to carry out every measure possible to ensure that the current rhinoplasty procedure is the patient’s last one. Having said that, some patients seek and subsequently undergo revision rhinoplasty. Surgeons should strive for a revision rate that approximates zero but should be able to tolerate one approximating 5%.
Preoperative Evaluation and Diagnosis
A separate chapter is specifically dedicated to this critically important topic. Throughout the initial consultation, a complete medical history and head and neck physical examination is carried out, with particular attention being directed to the nasal anatomy and function. The patient’s stated functional and aesthetic concerns are documented in the medical record and standardized digital photodocumentation takes place. An open conversation clarifying realistic expectations of what can be accomplished with rhinoplasty is carried out in light of the functional and aesthetic priorities discussed by both patient and surgeon.
The columellar scar is next to imperceptible if meticulous suturing techniques are used, and by itself it should not be a critical factor in deciding whether an endonasal or an external approach is carried out.
The meticulous and detail-oriented nature of open structure rhinoplasty requires the use of general endotracheal anesthesia or deep intravenous sedation. Appropriate anesthesia will aid in hemostasis, amnesia, and analgesia during and after the case.
Prior to arrival at the surgical facility, the patient is instructed to take an antiemetic (aprepitant 40 mg) for postoperative nausea, along with an anxiolytic (lorazepam 1 mg) as needed for anxiety. An intravenous line is initiated, and the patient is administered a dose of anxiolytic and narcotic for sedation (typically midazolam 1 mg) (Sublimaze [fentanyl] 50 micrograms). Additional doses of midazolam and fentanyl may be administered throughout the duration of the surgery, titrating to appropriate levels of analgesia, amnesia, and sedation. Preoperative antibiotics with broad-spectrum gram-positive coverage are dosed intravenously.
Monitoring includes continuous pulsoximetry, electrocardiography, blood pressure, and end-tidal CO 2 . General anesthesia can be induced with a propofol bolus in conjunction with a short- or intermediate-acting, nondepolarizing muscle relaxant such as atracurium. After intubation, general anesthesia is typically maintained with sevoflurane, which is favored for its fast onset and offset, its favorable cardiovascular profile, and its lower incidence of nausea, vomiting, and airway reactivity.
Use of a preformed endotracheal oral RAE tube allows the anesthesia tubing to run toward the patient’s feet, away from the surgical field. Care is taken to avoid undue traction of the mouth and nose with the endotracheal tube to minimize traction and asymmetries, which can mislead the surgeon.
Patient Position and Surgical Prep
The patient is placed in the supine position on the surgical bed, the head of which is tapered to allow the surgeon access to the head and neck region. Sufficient padding is layered underneath the patient, preventing pressure points and positioning-related injuries. After the induction of general anesthesia, the hair is taped or otherwise secured away from the face, and the face and nose are prepped and draped using standard sterile technique. Cotton-tipped applicators are used to clean the nasal vestibules. Eye lubrication is important to prevent corneal injuries.
Open Structure Rhinoplasty: The Basic Technique
A detailed description of the basic technique of open structure rhinoplasty is described in this chapter. This includes operative steps that are performed in most of our rhinoplasty procedures, such as the injection of local anesthetic, septal cartilage harvesting, skin and mucosal incisions, and dissection of the skin–soft tissue envelope (SSTE) from the underlying bony–cartilaginous framework.
We begin with analysis of the preoperative photographs ( Figure 5-1 ). A high dorsum can be seen with a mild to moderate bony–cartilaginous dorsal hump. The tip is ptotic, blunt, and underrotated. The tripod is larger than ideal. The medial crura are prominent, while the lateral crura are bulbous and convex. A larger than ideal pedestal overprojects the tripod. A caudal septal deflection deviates the nasal pyramid to the right. The caudal septum pulls the lip forward, blunting the nasolabial angle. The thickness of the SSTE can be described as thin to medium thickness.
The size and shape of the tripod must be optimized—notably, the bulbosity of the lateral crura and the bifidity of the medial crura.
As the anterior septal angle is reduced and the tip deprojected, the height of the dorsum will seem even higher. Thus, the bony–cartilaginous hump will require reduction.
Marks are made in the midline of the glabella, the midline of the tip, and the midline of the upper lip to serve as reference points. Note that the nose is deviated to the right.
The nasal cavity is packed loosely with Nu-Gauze/cottonoid pledgets moistened with a solution containing 4% cocaine. This is left in place for several minutes and removed prior to injecting the local anesthetic.
An equal mixture of 1% lidocaine with 1 : 100,000 epinephrine and 0.5% bupivacaine with 1 : 200,000 epinephrine is used for injection. The bupivacaine is included for its longer duration of action, which helps to reduce the amount of inhalational and parenteral anesthetic agents needed to maintain an adequate level of anesthesia during the procedure. The septum is injected using a 27-gauge needle on a 12-mL offset port syringe. The offset port allows easier visualization of the nasal cavity during injection. The septum is injected in a subperichondrial/subperiosteal plane with the bevel facing the septal cartilage, elevating, hydrodissecting, and causing blanching of the mucosa. The local anesthetic provides hydrodissection, vasoconstriction, and hemostasis. Both sides of the septum are injected with multiple needle sticks in a posterior-to-anterior fashion.
The membranous septum is not injected directly to prevent distortion of the columella and tip. Instead, the caudal edge of the septum is injected and the local anesthetic is allowed to diffuse into the area of the membranous septum on its own.
The pyriform aperture and anterior nasal floor are injected at multiple sites.
The lateral walls of the nose are injected via an intercartilaginous approach just superficial to the nasal bone periosteum. Injection is done as the needle is withdrawn, thereby avoiding injecting intravascularly.
The planned marginal incision is then injected at the caudal margin of the lower lateral cartilage (LLC). Multiple small injections are performed using a -inch 30-gauge needle. The nasal tip is manipulated between the thumb and index finger to evert the nostril and expose the caudal edge of the LLC.
The columella is then injected, with the needle just off the caudal edge of the medial crus. Only a very small amount (0.2 to 0.3 mL) is infiltrated to prevent tip distortion.
The interdomal region is injected with a very small amount of local anesthetic.
The cocaine-soaked nasal packing is left inside the nose while the patient is prepped and draped.
A limited amount of local anesthesia is injected, perhaps 7 to 8 mL in the septum and 1 to 2 mL in the tripod/lateral nasal walls. More injected anesthetic may distort the nasal structure, making the true appearance more difficult to judge. No local anesthesia is injected into the nasal dorsum to avoid distortion.
Tip projection can be measured with the projectimeter, which uses the bony points of the patient’s forehead and maxilla as fixed landmarks to provide a reproducible assessment of tip projection. Projection can be measured at various points during the surgery.
The open approach to the nose involves a mid-columellar inverted-V transverse incision with bilateral marginal incisions (see Figure 5-2 ). The mid-columellar incision is designed to break up the scar line avoiding cicatricial contracture. It is placed at an area where the underlying cartilage is closest to the skin, thus minimizing the risk of creating a depressed scar. If the incision is placed too low in the columella, where the skin is not as closely supported by the underlying medial crus, indentation of the scar can occur. Placement of the incision too high near the apex risks scar contracture, which can deform the nostrils.
The septum can be addressed first to correct deformities in this area and to obtain appropriate grafting material. A full transfixion incision is usually used to allow access to the caudal septum and nasal spine. This incision is made as close as possible to the caudal edge of the septum so as to maintain the integrity of the membranous septum, which will serve as part of the pocket for the columellar strut. The incision may be extended to the nasal spine if necessary. If caudal septal work is not required, a Killian incision may be used.
The perichondrium is incised, and the subperichondrial plane identified. The cartilage may be lightly cross-hatched with the No. 15 blade, then abraded with a dental amalgam packer, a Woodson elevator, or a cotton-tipped applicator to raise the perichondrium.
The mucoperichondrial flaps are raised bilaterally with the elevator, taking care to elevate past the borders of the septal cartilage and the perpendicular plate of the ethmoid, vomer, and maxillary crest ( Figure 5-3 ).
The cuts in the septal cartilage are made with a No. 15 blade leaving at least 15 mm at the caudal and dorsal struts for support ( Figure 5-4 ). The cartilage graft is then freed from its attachments to the bony septum using the dissector to atraumatically remove the cartilage from between the maxillary crest and vomer. Care must be taken to ensure the graft remains intact during the harvesting process. The harvested cartilage is stored in sterile saline or antibiotic solution.
The thickness of the cartilage graft varies depending on the location, and we use this to our advantage. The columellar strut is usually designed from the maxillary or dorsal portion of the graft, areas that are of relatively uniform thickness. When a shield graft is used, the thickened portion of the septum near the bony–cartilaginous junction is used for the distal end of the tapered tip graft ( Figure 5-5 ). Other grafts (alar, apex, spreader, etc.) can be made from the remaining cartilage.
Loss of projection may be seen after septoplasty, due to the transfixion incision, as this can divide one of the major tip support mechanisms.
Quilting sutures are placed using 4-0 gut on a straight Keith needle in a running horizontal mattress fashion to reapproximate the mucoperichondrial flaps and obliterate the dead space. A short (~1 cm) incision is made through one of the flaps overlying the maxillary crest to allow drainage of blood and serum from the septoplasty site. Silicone/silastic septal splints can be sutured onto each other using a 2-0 silk suture. If spreader grafts are planned, the septoplasty can be performed through a an anterior (external) approach.
The inverted-V mid-columellar incision is made with a No. 11 or 15 blade, taking care to avoid cutting into the medial crus of the LLC (see Figure 5-2 ). The incision must be kept perpendicular to the skin surface to avoid beveling the flap. If a No. 11 blade is used, a sawing motion is carried out for this portion of the procedure.
The mid-columellar incision is joined to the marginal incisions, which are created with the No. 15 blade at the caudal edges of the LLCs ( Figure 5-6 ). Medially, the marginal columellar incision is created approximately 2 mm behind the columellar rim. Laterally, the back edge of the blade can be used to palpate the caudal edge of the cartilage and guide the incision. The nostril is pinched between the 10-mm Joseph double hook and the surgeon’s finger and is everted. This especially helps with exposure of the marginal incision near the apex of the domes. It is very easy to inadvertently cut the LLC. The lateral and medial marginal incisions are connected along the undersurface of the soft tissue triangle, taking care to avoid notching the rim, which may lead to distortion of the nostril apex.
The angled Converse scissors are used to elevate the columellar portion of the flap. Care is taken to elevate the entire corner (junction between the mid-columellar and marginal incisions) with the flap.
The plane of dissection while elevating the columellar flap is just superficial to the medial crus—we try to keep this portion of the flap as thick as possible.
This is especially important in the patient with a thin SSTE. The flap should be of uniform thickness across the columella—the soft tissue between the medial crura is not elevated with the flap.
Dissection is continued along the LLC, elevating the SSTE using three-point retraction ( Figure 5-7 ). Two small skin hooks are held by the assistant, one on the skin flap and the second one along the undersurface of the medial crus. The surgeon uses the 10-mm double hook to retract the nostril rim. The skin hooks are repositioned as necessary to optimize exposure by the principle of traction and countertraction.