CHAPTER 36 Rhinoplasty

Surgical Philosophy

Technical advances in rhinoplasty techniques inexorably develop as the virtues of new operative procedures are proved by the creation of favorable long-term outcomes. The common philosophy surrounding rhinoplasty, however, remains constant: the operation is best achieved by conservative techniques based on (1) the exact anatomy encountered and (2) refinement techniques planned to achieve natural and normal-appearing outcomes (see Key Indicator Video on website). Radical departures from time-proven techniques should only be considered when significantly variant anatomic features are encountered.

Aesthetic and reconstructive rhinoplasty, universally acknowledged as the most elegant but most difficult of all plastic surgical procedures, has reached the 100th anniversary of its modern development. Although certain refinements in technique gained progressive acceptance during the first three fourths of the 20th century, the fundamental operation remained primarily a tissue reduction procedure, characterized by various degrees of excision (often rather profound) of the fundamental nasal anatomic components.

In the past 20 years, a striking revolution has occurred in the fine points of analysis and technique, guided by surgeons devoted to tissue reorientation and augmentation rather than resection, individualization of technique rather than a lock-step approach, and atraumatic tissue dissection in proper nasal cleavage planes. A more thorough understanding of and respect for the long-term surgical outcome now dominates and guides the selection of the surgical technique because surgeons are no longer content with satisfactory short-term results at the expense of risking future visual and functional misadventures. Thus all modifications to nasal structures should factor in the dynamic effects each maneuver exerts upon the immediate overall nasal appearance, in the nasal airway, and the anticipated control of the vagaries of healing nasal tissues. Clearly, the surgically altered nose continues to be modified by the healing process and certain inexorable aging phenomena during the lifetime of the patient. Thus it is seldom possible to designate a “final result” after nasal surgery.

The philosophy, approaches, and graduated techniques presented in this chapter seek to document and validate the long-term virtues of accurate detailed analysis and planning, atraumatic and conservative surgical techniques devoted to tissue repositioning and reorientation, and methods of exercising the highest control over the healing process.

Preoperative Patient Assessment

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.

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.

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.

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.

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.

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.

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.

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.

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).

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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Jun 5, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Rhinoplasty

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