Anatomic Evaluation

The final result of any rhinoplasty procedure is the consequence of the individual patient’s anatomy (Fig. 36-1) as much as the surgeon’s skill. No two noses are ever quite alike; it follows then that no single, standard procedure suffices to reconstruct every nose pleasingly. The ability to diagnose the possibilities and limitations inherent in each patient is an absolute prerequisite to achieving outstanding results. Sometimes patients with minimal deformities (a small hump; a minimally bulbous tip; a slightly overwide nose) are the best candidates for near-perfect surgical results (Fig. 36-2). Because the initial problem is minimal, however, this group of patients often expects and even demands perfection. More dramatic surgical results are possible in patients who demonstrate significant departures from an aesthetic ideal (a large hump; an elongated, drooping nose; a twisted nose); these patients might tolerate possible minor imperfections that result because the overall improvement is dramatic (Fig. 36-3). It is the fundamental responsibility of the surgeon to balance the wishes and desires of the patient with what is realistically possible given the anatomic limitations (or possibilities) inherent in each individual nose.

Figure 36-1. Practical nasal surgical anatomy. A, Lateral view. B, Base view.

Figure 36-2. Ideal candidate for rhinoplasty surgery. A, C, and E, Preoperative views. B, D, and F, Postoperative views.

Figure 36-3. Reconstruction of twisted nose, demonstrating major surgical changes. A and B, Frontal views. C and D, Lateral views. E and F, Base views.

The quality of the skin is an essential indicator of the surgical outcome and plays a significant role in preoperative planning. Extremely thick skin, rich in sebaceous glands and subcutaneous tissue, is the least ideal skin type for achieving desirable refinement and definition. Care should be taken not to overreduce the bony-cartilaginous skeleton in thick-skinned patients in a futile attempt to produce a much smaller nose. Failure of thick skin to contract favorably in this situation may lead to excess soft tissue scar, an amorphous nasal appearance, and even the dreaded soft tissue “pollybeak” (Fig. 36-4). When properly supported by the retention or creation of a vigorous supportive skeletal structure, elegant outcomes can be produced in thick-skinned patients with sufficient passage of time.

Figure 36-4. Revision repair of patient referred with typical soft tissue “pollybeak” deformity. Supratip scar carefully excised with restoration of appropriate tip-supratip relationship. Cartilage-only graft covers dorsum to smooth and improve contour of nasal skeleton. A, Preoperative view. B, Postoperative view.

Extremely thin skin, often pale, freckled, and nearly translucent, should also be recognized and respected for its inherent limitations. Although ideal for achieving critical definition, thin skin with sparse subcutaneous tissue provides almost no cushion to cover even the most minute of skeletal irregularities or contour imperfections, and therefore demands near-perfect surgery to achieve the desired natural result. Occasionally, patients with this anatomic condition demonstrate an undesirable progressive skin retraction and unattractive shrinkage over several years, rendering the nose unnatural and angular.

The ideal skin type falls somewhere between these two extremes, being neither too thick and oily nor too thin and delicate. It possesses enough subcutaneous tissue to provide a satisfactory cushion over the nasal skeleton but still allows critical definition to become apparent in a relatively short time after surgery. Evaluation of skin type is made by inspection and palpation—rolling the skin over the nasal skeleton and gently pinching it between the examining fingers.

A critical factor in assessing the candidate for rhinoplasty is the inherent strength and support of the nasal tip, referred to as the tip recoil. Finger depression of the tip toward the upper lid provides a quick and reliable test of the ability of the mobile tip’s structures to spring back into position (Fig. 36-5). The tip that possesses weak, somewhat flail alar cartilages does not tolerate an extensive sacrifice of tissue well and may require the addition of supportive struts to improve its long-term stable support. These weak tips often are accompanied by thin alar side walls and thin skin (see Fig. 36-31C). If the recoil is instantaneous and vigorous, and the tip cartilages resist the deforming influence of the finger, more definitive tip surgery can usually be performed without fear of substantial loss. The size, shape, attitude, and resilience of the alar cartilages can be estimated by palpation or ballottement of the lateral crus between two fingers surrounding its cephalic and caudal margins. During this assessment, the surgeon makes the all-important decision about whether to enhance, reduce, or carefully preserve the tip projection that exists preoperatively. Any asymmetry of the alar cartilages must be carefully noted for later correction.

Figure 36-5. Forceful depression of nasal tip structures, with assessment of tip recoil, guides surgeon to a better understanding of strength and integrity of tip-support mechanisms. This information is vital in selecting proper tip sculpture technique.

A gratifying amount of diagnostic information can be gained by palpating the internal vestibules of the nose with the thumb and forefinger surrounding the columella. Otherwise, undetected twists and angulations of the nasal septum, which may significantly influence the final functional and aesthetic appearance, may not be discovered. The width and length of the columella and the medial crura it contains are determined. Short medial crura will probably require supportive cartilaginous struts to support and minimally lengthen the columella and aid in rotation, if desirable; extremely flaring or overlong medial crura invite reduction in width and length as well as retropositioning. Information about the potential of the tip to undergo desirable cephalic rotation is gained by the exploring fingers, which determine whether the tip-lip complex is tethered by muscle and its inadequate length. It is also important to determine whether the central skeletal component of the nose (the quadrangular cartilage) is overlong and might interfere with satisfactory tip rotation (Fig. 36-6). The size and position of the nasal spine and its related caudal septal angle must also be evaluated.

Figure 36-6. A, A young patient demonstrating classic prolongation of caudal aspect of quadrangular cartilage, leading to webbed, indistinct nasolabial angle, overprojecting tip, and nasal proportion disharmony. B, Reduction of overlong caudal quadrangular cartilage with profile reduction combined with augmentation of deep nasofrontal angle with onlay cartilage graft. Note improvement in lip contour and overall nasal and facial proportion and balance.

An experienced surgeon can accomplish these visual and palpatory diagnostic exercises with precision and facility, often while eliciting further history from the patient. Detecting the minute but critical structural distinguishing characteristics of each individual’s nasal anatomy is the first and most important step toward a splendid surgical result.

Careful examination of the nasal fossae before and after shrinkage of the mucosa and turbinates is an essential component of the initial examination. Supplemental anterior and posterior rhinoscopy with the fiberoptic rhinoscope expands diagnostic information beyond that furnished by the nasal speculum alone. An overt, symptomatic deviation of the nasal septum is easily diagnosed; the deflected ethmoid plate, which may appear innocent but can be responsible for airway blockade after infraction of the bony side walls during an osteotomy (Fig. 36-7), may be easily overlooked by casual inspection. Internal examination confirms the condition of the internal nasal valves and their associated upper lateral cartilages and discovers whether the turbinates require repair or relocation to improve overall nasal function. If a septal perforation exists, its size and location may significantly influence the planned extent of the surgical procedure, particularly if substantial hump removal is planned.

Figure 36-7. Typical deviated ethmoid perpendicular plate. Narrowing the nasal bony side walls without initially correcting septal deviation inevitably leads to creation of nasal obstruction, even if none existed preoperatively.

Finally, the position and inclination of the nasofrontal and nasolabial angles, the shape and size of the alae, the overall width of the middle and upper thirds of the nose, and the relationship of the nose to the remainder of the facial features and landmarks are evaluated (Fig. 36-8). In particular, facial asymmetries (which are present more often than not) and the relationship of the chin projection to the nose should be documented (Fig. 36-9), particularly for patients who are unaware of the existence of such abnormalities. The routine use of a three-way mirror, facial photographs, and even computer imaging catalyze this vitally important communication process between the expectant patient and the cautious surgeon. This is the time, reinforced by later discussions, to make the patient aware of any and all limitations that the existent variant anatomy imposes on the desired surgical outcome. Realistic expectations and thoroughly informed consent are the keystones on which the most important surgical outcome—a happy patient—is achieved.

Figure 36-8. Relatively ideal proportions of the human face on frontal view.

Figure 36-9. Ideal proportions, lateral view.

Photography and Imaging

Standard and uniform color photography of a rhinoplasty patient, recorded before and serially after the surgical event, are as important to the rhinoplasty surgeon as radiographs are to bone specialists and electrocardiograms are to cardiologists. They are important guides to operative planning and execution, definitive records for evaluation by the surgeon and patient, invaluable teaching tools, and vital medicolegal records. Reliable methods of making standardized, consistently uniform photographs are described in Fig. 36-10. A rhinoplasty surgeon should either become expert in personally securing uniform and standard photographs or should arrange uncompromisingly for their provision by a medical photographer or knowledgeable assistant. Modern digital photography has multiple advantages including ease of storage and retrieval.

Figure 36-10. Ideal photographic views of rhinoplasty should include, at minimum, frontal (A), lateral (B), oblique (C), and basal (D). Smiling view is often helpful (Left oblique and lateral not shown). In special cases, close-up views may provide additional documentation.

Computer imaging has proved to be a useful communication tool in the consultative, preoperative period. Realistic and surgically attainable images must be presented to the patient to avoid misleading or spurious expectations. We emphasize that the computerized images represent a “realistic goal” of surgery and not a guaranteed outcome.

Laboratory Evaluation

The extent of indicated laboratory evaluations performed in the preoperative period depends on the needs of the individual patient. Whether the surgeon obtains an automated biochemical survey (SMA-12), a complete blood count, a urinalysis, a bleeding and coagulation survey (routinely consisting of a complete blood count, platelet count, bleeding and clotting time, and partial thromboplastin time), or a combination thereof will depend on the patient’s history and individual needs. This information is augmented by a thorough history of any personal or familial bleeding disorder. Of particular importance is any history of recent ingestion of aspirin or aspirin-containing drugs or herbal and alternative medicines, which must be stopped at least 2 weeks before the scheduled surgery. Many of these nonstandard drugs can lead to untoward bleeding during or following nasal surgery and thus are to be avoided.

Routine sinus radiographs are requested only if nasal and sinus disease is suspected; radiographs of the nasal skeleton usually provide little useful information that cannot be better obtained from minute inspection and palpation. When nasal implants or foreign bodies are suspected, computed tomography (CT) scans can be invaluable in pinpointing their position, composition, and extent.

Anesthesia and Analgesia

Successful rhinoplasty depends on a careful preoperative analysis, an exacting operative technique, and favorable postoperative healing.

Each surgical step in the correction of the nose is interrelated and interdependent with the other steps; the success of each step depends in no small measure on the preceding ones. Because the administration of infiltrations anesthesia is the initial surgical step in rhinoplasty, a well-planned and well-executed technique that avoids tissue distortion is necessary for a successfully controlled procedure (Fig. 36-11).

Figure 36-11. The components of a successful rhinoplasty.

Improper administration of anesthesia results in an uncomfortable, agitated patient and a bloody operative field, which at best hinders surgery. Correct anesthetic administration commonly results in a comfortable, relaxed patient and a relatively bloodless operative field, permitting precise anatomic dissection.

Just as there are a multitude of rhinoplasty techniques, so are there various approaches to nasal anesthesia. Experience suggests that a combination of monitored intravenous analgesia with local topical and infiltration anesthesia works well for rhinoplasty. General endotracheal anesthesia can be safely used for routine nasal surgery and may be chosen according to the preference of the patient and surgeon.

Surgical Planes

To achieve the goals of local anesthesia fully, it is important to appreciate, identify, and correctly use the surgical planes of the nose. The importance of anatomic tissue planes is stressed throughout surgical training because dissection within these favorable planes facilitates surgery with minimal bleeding and postoperative scarring.

Within the nose, four distinct dissection planes can be identified. An extraperiosteal plane exists lateral and medial to the ascending process of the maxilla along the intended course of the lateral osteotomies. Infiltration of the local anesthetic on both sides of the ascending process aids remarkably in eliminating or reducing bleeding after a lateral osteotomy (Fig. 36-12). A second plane exists in the submucoperichondrial and submucoperiosteal spaces flanking the nasal septum. Infiltration of the local anesthetic into this plane results in a hydraulic dissection of the septal flap, facilitating elevation and preservation of flap integrity (Fig. 36-13). Of greatest importance is the surgical plane occupying the immediate supraperichondrial and supraperiosteal regions over the lower and upper cartilages and nasal bones that exist just below the subcutaneous tissue layer (Fig. 36-14). It is entered in all rhinoplasty operations. Infiltrating and operating in this plane produces a virtually bloodless field for delicate precision surgery. The fourth relatively avascular and favorable dissection plane exists in the submucoperichondrial space flanking the septal cartilage on either side.

Figure 36-12. Anesthetic infiltration of internal (medial) aspects of ascending process of maxilla as well as lateral surface creates vasoconstricted pathway for progression of lateral osteotomy, thereby reducing or eliminating bleeding and edema.

Figure 36-13. A, Anesthetic infiltration of submucoperichondrial plane results in “hydraulic dissection” of mucoperichondrial flap. B, Facile elevation of mucoperichondrial septal flap is more easily accomplished when proper anesthetic infiltration is carried out.

Figure 36-14. Increments of cartilaginous dorsum are shaved away with a sharp knife under direct vision until a satisfactory tip-supratip relationship is established. Except in unusual circumstances, underlying mucoperichondrium bridging upper lateral cartilages to quadrangular cartilage is always preserved. The hump can alternatively be reduced by resecting cartilage and bony elements en bloc manner.

A paucity of vascular and neural structures exists in these planes; anesthetic infiltration into these planes misses the vessels and nerves that lie more superficial in the subcutaneous tissue and dermis. When the anesthetic is injected into the proper planes, it diffuses more readily and requires only small amounts (usually 3.5 to 5 mL) to obtain the desired anesthetic and vasoconstrictive effects. If the infiltration is placed in the subcutaneous tissue or epithelium overlying these planes, larger quantities are needed to obtain these effects, and there is a tendency to distort and “balloon” the nose, creating a distortion that leads to inaccurate judgment. By identifying and using the proper dissection planes, only small amounts of anesthetic are needed to achieve maximal anesthesia and vasoconstriction with consequent minimal nasal distortion.

Preoperative Medication and Intravenous Analgesia

Local infiltration anesthesia is administered after the patient has been sedated with preoperative medication and intravenous analgesia. It is important that the patient not receive many different families of drugs before or during surgery. Combinations of drugs, particularly when they are intermingled with intravenous medications given during surgery, are often unpredictable in their individual and combined effectiveness. Any drug reaction that can arise from the use of multiple families of pharmacologic agents is confusing to treat and may be impossible to counteract intelligently.

Close cooperation between the surgeon and the anesthesiologist is important at this time as well as throughout the operation. Each is responsible for the patient’s safety and well-being, and each catalyzes the operative process by a healthy respect for the other’s responsibilities.

For increased comfort, the patient is maintained in the reverse Trendelenburg position with the head elevated. This enhances vasoconstriction and facilitates venous and lymphatic drainage.

Infiltration Anesthesia

For infiltration anesthesia, 1% lidocaine with a 1 : 100,000 dilution of epinephrine is preferred. The weaker solution is used in older patients or in those with any question of cardiovascular or peripheral vascular disease. Both concentrations of epinephrine produce profound vasoconstriction if incisions are delayed for 10 to 15 minutes after the final injection. The concentration of 1% lidocaine is sufficient to produce excellent anesthesia and has an effective duration of 1.5 to 2 hours.

Except in unusual cases, a total of 5 to 10 mL of the solution, sparingly injected into the proper surgical planes, is sufficient to produce profound vasoconstriction and complete nasal anesthesia with no significant tissue distortion. No effort is made to block specific nerves. If septal reconstruction is required, an additional 3 to 5 mL of the anesthetic is injected into the septal submucoperichondrial and submucoperiosteal planes to aid in the hydraulic dissection of the septal flap.

The infiltration of the local anesthetic is initiated by retracting the ala cephalically with the thumb and forefinger, exposing the caudal edge of the upper lateral cartilage (specula or retractors are unnecessary and redundant at this point). A long 27-gauge needle is placed parallel to the long axis of the exposed upper lateral cartilage, and with a quick stabbing motion the needle penetrates the epithelium, usually with minimal sensation to the patient (Fig. 36-15A).

Figure 36-15. A, Initial advancement of needle in proper plane over bony and cartilaginous vaults, with infiltration in plane between nasal skeleton and subcutaneous tissues. B, Infiltration of lateral wall of nose, intimate to nasal skeleton. C and D, Rotation of needle within soft tissues to effect further anesthesia of lateral and dorsal nasal tissues. E and F, Infiltration of nasal base and floor with one-needle penetration. G, Intended pathway of low lateral osteotomies. Infiltration of local anesthetic should surround this pathway medial and lateral to ascending process.

The needle is advanced along the lateral wall of the dorsum, hugging the perichondrium of the upper lateral cartilages and the periosteum of the nasal bones, thus remaining in the proper plane. Identification of this plane is enhanced by lifting the soft tissues overlying the nasal dorsum with thumb and forefinger.

A minimal quantity of anesthetic solution, usually less than 0.5 mL, is deposited into this plane as the needle is withdrawn to but not beyond the point of initial penetration (see Fig. 36-15B). If the nose becomes distorted during this maneuver, the needle is not in the proper plane, and the infiltration stops until the plane is located. With alternate slight rotation of the needle laterally and medially over the dorsum (see Fig. 36-15C and D), the procedure is repeated until the anesthetic is deposited in the proper plane over the area to be dissected. The procedure is repeated on the opposite side. With this method, only two injection penetrations are sufficient to anesthetize the nasal dorsum.

Anesthesia of the base of the nose and columella is accomplished next. The needle penetrates the skin at the junction of the floor of the right nostril and columella and is advanced to a point just beyond the left alar facial junction (see Fig. 36-15E). Infiltration occurs as the needle is withdrawn to the columella. Without removal, the needle is rotated and advanced into the columella. Again, a small amount of anesthetic is deposited as the needle is withdrawn. Sparing the patient an additional needle prick, the needle is rotated into the right nasal base, which is anesthetized in a similar fashion (see Fig. 36-15F).

The technique of nasal tip anesthetic infiltration depends on the type of planned nasal tip incision. If a transcartilaginous incision is intended, the vestibular skin on the undersurface of the lower lateral cartilage is exposed and everted by pressure above the nostril. The solution is deposited along the course of the proposed incision in the natural plane beneath the perichondrium. Surgical elevation and preservation of an intact vestibular skin flap is thereby facilitated. If delivery of the alar cartilage is contemplated, the anesthetic is infiltrated in the soft tissue along the extent of the planned incision at the caudal margin of the cartilage. If an open approach is contemplated, additional infiltration occurs in the interdomal region, the infratip lobule, and the columella.

The anesthetic can then be deposited along the course of the lateral osteotomies (see Fig. 36-15A and B) or, if desired, this can be deferred until later in the operation. This delay adds a safety measure to the procedure by allowing the patient to metabolize the initial lidocaine and epinephrine before adding any additional solution. The margin of the piriform aperture just above the leading anterior edge of the inferior turbinate is brought into sharp relief by surrounding it with the blades of a small nasal speculum. The needle is inserted at this site, and a small amount of medication is injected. The needle is advanced lateral to and then medial to the ascending process of the maxilla along the intended path of the lateral osteotomies (see Fig. 36-15G

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