Online Contents
Animations
Development of Midvault Weakness after Surgery Animation 14.1
Development of a Dorsal Depression after Surgery Animation 14.2
Development of Midvault Narrowing and Tip Derotation Animation 14.3
Improvement of Tip Definition over Time Animation 14.4
Pearls
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The nose should appear close to optimal a year after surgery as the major soft tissue swelling subsides and should retain the desired shape for the rest of the patient’s life.
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The results of rhinoplasty continuously evolve due to the effects of gravity and aging.
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A common example of a flaw that may not easily be detected during the surgery but may become discernible over a period of years is an inverted V deformity related to a medial shift of the upper lateral cartilage.
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Violation of the nasal muscles could result in some irregularities on animation months or years later that are not noticeable during the immediate postoperative period.
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The firmer the structure under the skin, the more likely it is that the overlying soft tissues will become thinner with time.
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It is crucial to bevel the graft margins to avoid a harsh appearance of the frame over a long term follow up.
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On patients with thinner skin, use of conchal cartilage as an onlay graft with preserved perichondrium draped over it or a gently bruised septal cartilage graft is superior to intact septal or costal cartilage graft.
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One common post-rhinoplasty occurrence is tip rotation caudally. This can be prevented with a tip rotation suture using a permanent material such as 5-0 clear nylon.
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Patients who smoke experience a loss of skin elasticity and thickness more quickly in the cephalic half of the nose, while they have a greater propensity to develop supratip deformity due to hyperactive sebaceous glands and thickening of the soft tissues with time.
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Sun exposure also accelerates aging and reduces skin elasticity, resulting in the loss of soft tissue volume, thus revealing minor imperfections over a period of years.
Although we all advocate not making any judgment about rhinoplasty results until at least 1 year after surgery, this time frame has been arbitrarily assigned and there is no scientific evidence that nose remodeling ceases after 1 year. In fact, it is my firm conviction that the results of rhinoplasty evolve continuously. This is true of the face and body, since gravity and aging alter soft tissue thickness and reduce the effectiveness of concealment of residual flaws by the soft tissues. However, one can argue that most changes occur during the first postoperative year. The results surgery is aiming for should stand the test of the time, which means that the nose should appear close to optimal a year later as the major soft tissue swelling subsides, and should retain the desired shape for the rest of the patient’s life. There are three elements that interact with the nose over time: soft tissue thickness, nose frame quality, and environmental factors. We will discuss each separately.
Soft Tissue Thickness
As discussed in Chapter 1 , the soft tissues of the nose encompass the skin, the subcutaneous layers, including the superficial musculoaponeurotic system and muscles, and the periosteum. The thickness of the skin is variable, depending on gender and age. As we age, the thickness of the skin undoubtedly diminishes. Therefore, over decades, nose frame imperfections that were veiled with a blanket of soft tissues may become discernible. It is therefore crucial to observe the remodeled frame as thoroughly as possible using an open technique to eliminate minor flaws that may not be easily detected by palpation of the skin after the injection of vasoconstrictive materials and owing to swelling during the surgery. A common example of such a flaw is medial shift of the upper lateral cartilages, which may not be readily detected intraoperatively. Many inverted V deformities become evident over a period of 6 months to a year and sometimes several years after the surgery, depending on the thickness of the soft tissue. The reality is that swollen tissues during the early stages and scar tissue later may hide this defect, only for it to become noticeable when the swelling subsides and the scar tissue remodels. To prevent this displeasing outcome, the frame of the nose needs to be arranged in such a way that, whether the skin is thick or thin, the dorsal lines will remain congruent. Often, by compressing the skin and temporarily relieving the soft tissue edema during surgery, one can, to some degree, detect an inverted V deformity that may not be obvious. This small maneuver can establish the need for spreader grafts and obviate a revision surgery. Thinning of the soft tissues as a result of aging is detrimental in a large majority of patients ( Figures 14.1–14.3 ; Animations 14.1, 14.2, 14.3; Boxes 14.1–14.3 ). However, patients with thick skin often benefit from time effects, and better definition, especially in the tip and supratip area, is observed as time elapses ( Figure 14.4 ; Box 14.4 ; Animation 14.4). It may take several years before this type of favorable change is visible.
