Aesthetic and reconstructive rhinoplasty is commonly acknowledged as the most demanding and difficult of the plastic surgical procedures. Although many technical advances have occurred throughout the past century, its fundamental philosophy remains constant. This philosophy involves significant planning and conservative surgical changes to achieve a natural-appearing result. Initially, the operation generally involved a tissue reduction procedure with excision of various nasal anatomic components. More recently, rhinoplasty has evolved into a procedure that involves tissue reorientation and augmentation, with careful attention to long-term surgical outcome.
Personal Philosophy
Rhinoplasty is a complex operation that requires precise preoperative diagnosis to select the appropriate surgical technique. Owing to variations in nasal anatomy and aesthetic expectations, no single technique is appropriate for all patients. Each rhinoplasty patient presents the surgeon with a diversity of nasal anatomy, contours, and proportions that require a series of organized maneuvers tailored to the patient’s anatomic and functional needs. The surgeon must also be skilled at manipulating and controlling the dynamics of postoperative healing to attain optimal long-term aesthetic results. A necessary prerequisite is the skill to visualize the ultimate long-term healed result while manipulating the nasal structures.
Anatomy
Aging of the nasal structures and external contour of the nose is influenced by a variety of genetic and environmental factors. Additionally, the nasal shape changes over time as well. In children, the nasal dorsum is typically concave and assumes a more straight or convex shape in early adult life. This convexity is further enhanced in midlife by the development of a drooping, ptotic tip. In addition to these changes to the appearance of the nose, nasal function tends to deteriorate over time as the nasal airway changes.
As patients age, the skin thins with loss of elasticity, subcutaneous fat deposits resorb, and the underlying soft tissues atrophy. With these changes, the underlying support structures of the nose, such as the lower lateral cartilages and nasal bones, become skeletonized or visible. In addition, skin hydration is diminished, and the skin becomes less pliable. This affects the skin’s ability to contract and redrape after the cartilaginous and bony structures of the nose are reduced.
The most significant changes over time occur in the upper and lower lateral cartilages. These cartilages are connected by a fibrous union at the cephalic margin of the lateral crura, the scroll region. As the nose ages, the upper and lower lateral cartilages begin to separate and fragment. This may result in collapse of the internal nasal valve and lateral wall. As one ages, the middle nasal vault will tend to collapse as the upper lateral cartilages move inferomedially. Loss of support of the medial crura and stretching of the fibrous attachments from the posterior septal angle and nasal spine to the medial crural footplates result in their posterior movement and retraction of the columella. These changes also occur by loss of the fat pad below the medial crura and resorption of the premaxilla. With loss of support of the medial crura and separation of the lateral crura from the upper lateral cartilages, the nasal tip may become ptotic, with an appearance of increased length and a more acute nasolabial angle.
With aging, the nasal bones may become brittle and are more readily fractured. Care must be taken during osteotomies to avoid excessive narrowing of the bony vault or comminuted fractures of the nasal bones. Periosteal elevation is not recommended in the aging patient and, if used, should not extend to the point of the intended lateral osteotomies, to avoid loss of periosteal support. Although undesirable in the younger patient, greenstick fractures can be effective in the older patient. Finally, dorsal hump reduction must be executed with great precision to minimize irregularities of the bony nasal vault as the skin over the dorsum tends to be very thin.
Preoperative Assessment
Preoperative assessment of the rhinoplasty patient includes the assessment not only of the anatomic and functional components but also the emotional and psychological factors. As with all facial aesthetic surgery, it is important for the physician to discuss motivation and aesthetic goals of rhinoplasty surgery with the patient. It is critical to elucidate what aesthetic changes the patient desires. Older patients have developed a self-image over many years and must be prepared for the planned surgical changes. Many older patients do not want to look dramatically different, and thus conservative changes are generally most appropriate. Patients who desire dramatic changes warrant careful evaluation prior to consideration as surgical candidates.
In this age group, a thorough preoperative medical examination is mandatory. Many of these patients have comorbid medical conditions. A careful medical history and physical examination are critical prior to performing this type of surgery. It is often a good idea to consult with the patient’s primary care physician prior to scheduling surgery. Many of these patients take medications that can affect clotting; these medications should be stopped at least 2 weeks before surgery.
Surgical Technique
Preoperative Considerations
The surgical approaches to the nose include nondelivery techniques (cartilage-splitting or retrograde approach), delivery of bilateral chondrocutaneous flaps, and the external rhinoplasty approach. Selection of the approach should be based on both operative objectives and surgical experience. When only conservative volume reduction of the lateral crura and dorsal hump reduction are planned, a nondelivery approach (cartilage-splitting or retrograde approach) will suffice. However, when more complex nasal tip work is required, delivery of bilateral chondrocutaneous flaps or the external rhinoplasty approach should be used. The external approach is preferred when complex tip grafting or middle nasal vault reconstruction is planned. Regardless, the surgeon should select the least invasive approach possible to avoid disruption of nasal support mechanisms and maximize the functional and aesthetic result.
External incisions can be used with greater frequency in older patients because the skin is less likely to scar unfavorably. Nasal skin in the aging patient also has multiple rhytids that can aid in camouflage. Even though it is rarely necessary, direct excision of skin from the nasal dorsum or supratip can be performed to aid redraping of the skin or elevating the severely ptotic nasal tip. Because of the thin skin found in the aging nose, even the smallest irregularities or asymmetries can become noticeable. As a result, debulking of underlying subcutaneous fat and muscle tissue should not be performed. This subcutaneous tissue should be preserved to maximize camouflage of the cartilage and bone. Tip grafts should also be limited unless the patient has medium to thick skin. If they are used, they should be carefully sculpted and camouflaged to avoid visible edges. With thin skin, a thin layer of perichondrium or superficial temporal fascia can be applied over the graft, with an understanding that it will create temporary edema of the grafted area that should resolve over 6 to 12 months.
When treating the aging nose, the nasal tip should be managed first to set tip projection and rotation before completing profile alignment. After setting appropriate tip projection, dorsal hump reduction may not be needed. Frequently, older patients will also benefit from augmentation of the radix to create a straight profile. This strategy of increasing tip projection and raising the radix allows the surgeon to preserve a high dorsal profile while also creating a favorable tip-supratip relationship ( Figure 33-1 ). As mentioned earlier, only conservative changes should be made in the nasal contour because older patients tend to have a set self-image. The nose should also be in harmony with the patient’s other facial features.
The External Approach
The patient is first injected with 1% lidocaine with 1 : 100,000 epinephrine into the nasal tip, between and around the domes, down the columella, along the site of the marginal incision, and along the lateral wall of the nose. Additional injections high on the nasal septum and along the osteotomy sites are then placed. An inverted-V columellar incision is then marked, midway between the base of the nose and the top of the nostrils. A transcolumellar incision is executed with a No. 11 blade. Care must be taken to avoid damaging the caudal margin of the medial crura. Marginal incisions are then made along the caudal margin of the lateral crura, which are extended to meet the columellar incision.
After completing the incisions, angled Converse scissors are used to elevate the skin off the medial crura. Once the columellar flap is elevated off the medial crura, dissection is advanced laterally to expose the lateral crura. A thin layer of perichondrium is left on the surface of the lower lateral cartilages. The anterior septal angle is identified, with exposure of the middle nasal vault in the midline. Blunt dissection is continued to the rhinion, which may be followed by subperiosteal dissection of the skin off the nasal dorsum up to the nasion if profile alignment is necessary. If a radix graft is planned, then a narrow pocket should be dissected in the midline over the radix. This narrow pocket will prevent shifting of a radix graft if radix augmentation is necessary.
Septal Surgery
When performing septal surgery in the older patient, dissection of the mucosal flaps should be limited because the mucoperichondrium is thinner and drier. A substantial L-shaped septal strut should be preserved to support the lower two thirds of the nose. We prefer to leave at least a 2-cm anterior septal strut and 1.5-cm caudal strut for support. Extra cartilage should be left at the osseocartilaginous junction to avoid loss of dorsal septal support. A Killian incision is preferred because of its excellent exposure without compromise of the support attachments between the feet of the medial crura and the caudal septum. A hemitransfixion incision can be used if exposure of both sides of the caudal nasal septum is required. The hemitransfixion or full transfixion incision can sometimes lead to a loss of support due to disruption of some of the attachments between the medial crura and caudal septum. When a decrease in tip projection is desired, a full transfixion incision can be used to disrupt these attachments.
When exposing the septal cartilage in the aging patient, it is generally preferable to raise a mucoperichondrial flap on only one side of the septum, to preserve the vascular supply of the contralateral side and minimize chances of hematoma formation. After completion of the septal surgery, a running 4-0 plain catgut mattress suture is used to approximate the mucoperichondrial flaps and prevent fluid collection and hematoma formation. By limiting septal surgery, nasal packing can be minimized or avoided. The surgeon should be aware that the septal cartilage may be partially calcified, which leaves the surgeon with less cartilage for harvesting or grafting.
In some patients, it may be necessary to dissect between the medial crura to access the caudal septum. Patients with a deviated caudal septum may benefit from this approach to allow correction of the deformity. Other patients with poor tip support could benefit from stabilization of the nasal base through this approach.
Ptotic Nasal Tip
As the nose ages, the nasal tip frequently droops, creating a ptotic nasal tip. This change in nasal contour gives an elongated appearance. Patients that have shorter medial crura are more likely to develop tip ptosis due to lack of support. Patients with long medial crura that wrap around the nasal spine and caudal septum are less likely to develop tip ptosis ( Figure 33-2 ). Severe ptosis of the nasal tip can also result in nasal airway compromise by altering the pathway of inspiratory air currents. Correction of the ptotic nasal tip generally involves increasing nasal tip rotation and projection. As demonstrated by the tripod concept described by Anderson, ptosis of the nasal tip can usually be corrected by supporting the medial and intermediate crura or by shortening the lateral crura.
We typically use a graduated approach for correction of the ptotic nasal tip by initially considering placing a sutured-in-place columellar strut between the medial crura. We have found this to be particularly effective if the dependent lobule is caused by buckling of the medial or intermediate crura. A sutured-in-place columellar strut both provides support and straightens buckled medial and intermediate crura. A straight rectangular piece of septal cartilage is placed in a precise pocket created between the medial and intermediate crura. The columellar strut is fixed into position using a 5-0 plain catgut suture on a straight septal needle. The strut is easily applied using the external rhinoplasty approach, which allows maximal visualization, precise placement, and suture fixation of the graft. These struts can also be applied using a small endonasal incision placed just caudal to the caudal margin of the medial crura. Once the incision is made, a precise pocket is made between the medial crura for graft placement and suture fixation.
In many patients, a columellar strut will not provide sufficient support to the nasal base. These patients will require more significant structural support. One option is to suture the medial crura to the caudal septum. This maneuver will shorten the nose and support the nasal base. This technique should be used only when the caudal septum is long and would otherwise require shortening. Another option is to use a caudal extension graft. Such a graft is typically overlapped and sutured to the existing caudal septum. Then the medial crura are sutured to the caudal margin of the caudal extension graft to stabilize the nasal base and reposition the nasal tip. The caudal extension graft must be in the midline and oriented to increase tip rotation. Fixation of the medial crura to the caudal septum or an extension graft provides increased tip support ( Figure 33-3 ). Such fixation creates moderate rigidity of the nasal tip that can be discussed with the patient preoperatively.
If stabilizing the nasal base does not adequately correct the ptotic nasal tip, then additional surgical maneuvers must be used to increase tip rotation. The objective of these maneuvers is to rotate the nasal tip by recruiting lateral crura medially. Placement of a transdomal suture recruits lateral crura medially to increase tip projection and rotation. Without violating the underlying vestibular skin, a 5-0 clear nylon suture is placed in a horizontal mattress fashion across both domes. To recruit the lateral crura medially, the lateral bite of the suture extends lateral to the anatomic dome. This suture narrows the nasal tip by approximating the domes and creating a more acute domal angle, in addition to increasing tip projection and rotation. In some cases, the transdomal suture can further compromise the nasal airway if the lateral crura protrude into the airway. Such obstruction can be avoided by using an alar batten graft or lateral crural strut graft to lateralize the offending lateral segment of the lateral crus. If the transdomal suture does not correct the ptotic nasal tip, it may be necessary to perform a more aggressive maneuver that shortens the lateral crura.
The lateral crural overlay technique is a procedure that increases tip rotation by shortening the lateral crura. In this technique, the lateral crura are incised at the midpoint, and the medial segment is dissected from the underlying vestibular skin ( Figure 33-4 ). The cut ends of cartilage are then overlapped (3 mm or 4 mm) and resutured with two 5-0 clear nylon mattress sutures to reconstitute the lateral crural segments into their shortened configuration. The degree of tip rotation is directly proportional to the degree of overlap (shortening) of the lateral crura. Symmetric alignment of the lateral crura must be achieved to avoid tip or alar margin asymmetry ( Figure 33-5 ).
