Rhinoplasty

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Discuss desired preoperative aesthetic and functional assessment of the postsurgical nose with rhinoplasty patients. 2. Identify factors that have the potential to affect procedural outcomes. 3. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function. 4. Recognize and manage complications following rhinoplasty. SUMMARY: Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery. Over the past 20 years, the trend has shifted away from ablative techniques involving reduction or division of the osseocartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. Accurate preoperative systematic nasal analysis and evaluation of the nasal airway, along with identification of both the patient's expectations and the surgeon's goals, form the foundation for success. Intraoperatively, adequate anatomical exposure of the nasal deformity; preservation and restoration of the normal anatomy; correction of the deformity using incremental control, maintenance, and restoration of the nasal airway; and recognition of the dynamic interplays among the composite of maneuvers are required. During postoperative recovery, care and reassurance combined with an ability to recognize and manage complications lead to successful outcomes following rhinoplasty.     

Nasal augmentation with Surgicel-wrapped diced cartilage: a review of 67 consecutive cases

Cartilage grafting has been used extensively to correct both the functional and aesthetic aspects of the nasal framework. The technique described by Erol ( 105: 2229, 2000) uses Surgicel-wrapped diced cartilage grafts in rhinoplasties. The advantages include its ease of preparation, the large volume of graft substrate available for use, and the avoidance of contour irregularities in the areas of placement. A retrospective case review of 67 consecutive patients who were treated with a Surgicel-wrapped diced cartilage graft as part of an aesthetic and/or functional rhinoplasty, in a 5-year period between 1995 and 2000, was performed in this study. All cases of congenital nasal deformities or deformities caused by trauma or tumors in which the technique was used were excluded. The charts were reviewed to determine demographic variables, the surgical procedures performed, prior operations, the rhinoplasty approach used, and the graft donor and recipient sites. Preoperative and postoperative photographs were examined, and the results were assessed. Data on the donor and recipient sites, complications, and the necessity for revisionary procedures were tabulated. There were two complications, namely, an infection, which resolved with aspiration and oral antibiotic therapy, and a recurrence of a dorsal depression, which necessitated repeated augmentation within 6 months. The technique of using Surgicel-wrapped diced cartilage proved to be effective for the augmentation of various areas of the nose. The complication and revision rates were acceptable and comparable to those of other techniques. Patient satisfaction with the aesthetic results was rated highly, with no reports of graft extrusion or contour irregularities. This technique is recommended for nasal augmentation and contouring for selected rhinoplasty patients.     

Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution

To achieve success in rhinoplasty, the plastic surgeon takes advantage of numerous intraoperative techniques designed to manipulate nasal soft tissue and the osseocartilaginous framework. Although the postoperative result may meet preoperative aesthetic goals, an element of nasal airway obstruction can persist from failure to acknowledge the role of inferior turbinates. Surgically responsive inferior turbinate hypertrophy is frequently not addressed secondary to inadequate history taking, incomplete physical examination, and/or surgeon reluctance to handle these sensitive structures.The goal of this article is to discuss the anatomy and physiology of the inferior turbinates, to present the role for inferior turbinate surgery during rhinoplasty, and to delineate the evolution of the current technique of submucosal resection of the inferior turbinates. Over the past 14 years, the senior author (R.J.R.) has performed inferior turbinates surgery on 648 patients as part of a rhinoplasty.     

External approach for secondary rhinoplasty

A systematic approach, using the external rhinoplasty technique, is presented to aid the plastic surgeon in obtaining improved aesthetic and functional results in patients with postoperative nasal deformities. In over 100 external rhinoplasties, there were no problems with the stairstep transcolumellar incision used to provide complete visualization of the underlying nasal framework. The external approach allows for a more accurate intraoperative anatomic diagnosis and subsequent complete correction of the nasal deformity. Three case reports are presented to demonstrate the indications and versatility of the external approach in secondary rhinoplasty.     

The "iatrogenic-hanging columella": preserving columellar contour after tip retroprojection

This article discusses a method for treating the ultraprojecting tip by the resection of columellar skin in open rhinoplasty. Lack of postoperative contraction of columellar skin and soft tissue may result in an "iatrogenic-hanging columella." Columellar skin resection frequently produces its own deformities because of a discrepancy in the width of the columellar base side and the infralobular flap side. The ultraprojecting tip was present in 56 of 660 consecutive rhinoplasty patients (8 percent) over 8 years (1991 to 1998). Of these 56 patients, 48 underwent partial resection of the infralobular skin flap. Of these 48 patients, eight (17 percent) required secondary skin revision of the columellar resection area. The technique was then modified since 1998. Over 2 years, 13 of 129 consecutive rhinoplasty patients (10 percent) were judged to have an ultraprojecting tip. Of these, eight patients were treated with a modification in the technique by resecting skin on the posterior columellar base. No resection areas were revised in the second series. Of the 789 patients in both series, 647 (82 percent) underwent primary rhinoplasties, 126 (16 percent) had secondary rhinoplasties, and 16 (2 percent) had tertiary rhinoplasties. The treatment of excess columella skin adds a subtle aesthetic improvement to the postoperative nasal contour. By resecting skin on the posterior columellar base or the posterior columellar base and, rarely, the anterior flap, an iatrogenic-hanging columella can be avoided.     

Extended incision in open-approach rhinoplasty for asians

The purpose of this study was to introduce an extended incision in open-approach rhinoplasty for obtaining greater satisfaction in aesthetic rhinoplasty for Asians. This incision is the same as for the usual open rhinoplasty incision, but it is extended along the caudal border of the footplates of the medial crura onto the floor of the nasal vestibule to access the footplates of the medial crura more easily. This simple extended incision enabled the authors to achieve further tip projection because the pressure of the skin flap on the tip was reduced. By approximating the lateral curves of the medial crural footplates, the width and the length of the columella were narrowed and lengthened, respectively. The columella was also advanced caudally; thus, the shape of the nostrils could also be elongated. In addition, a cartilage graft or an implant insertion for alar base augmentation could be performed through this extended incision without an additional incision. Another advantage was that in correction of caudal septal deviation, displaced septal cartilage could be repositioned by suturing to the periosteum or soft tissue around the anterior nasal spine without drilling into it through an intraoral incision. Fifty-one consecutive patients who underwent this extended open-approach rhinoplasty between August of 1999 and September of 2000 were included in this study. A total of 40 patients had an adequate follow-up time of over 6 months. Patient satisfaction and postoperative complications were recorded. The majority of the patients (35 of 40) were satisfied with the results of the procedure. Two patients had complications of nostril-scar contracture requiring close follow-up. There were no cases of implant extrusion, displacement, or infection. No patients experienced transcolumellar or extended-incision scarring. Although further studies and longer follow-up are needed to determine the value of this incision, the authors believe that the addition of the extended incision in open-approach rhinoplasty is safe and reliable for effecting better results for Asians.     

Rhinoplasty: personal evolution and milestones

Over the past 35 years, aesthetic rhinoplasty has evolved from a generic, reductive operation to a highly individualized, problem-specific operation that often combines augmentation with reduction. The author's experience has been marked by the following conceptual and technical milestones that have contributed to an ongoing exploration and advancement of nasal surgery: (1) vestibular stenosis: diagnosis of a surgical consequence; (2) etiology and treatment of supratip deformity: the dynamic relationship of soft-tissue contour to skeleton; (3) etiology and treatment of the tip with inadequate projection: tip graft design; (4) practical aesthetics of balance: the augmentation-reduction approach to rhinoplasty; (5) support of the middle vault: functional and aesthetic effects; (6) malposition of the lateral crura: recognition and management; and (7) the significance of the middle crura: clinical and aesthetic considerations.     

Analysis of risks and aesthetics in a consecutive series of tissue expansion breast reconstructions.

A consecutive series of 73 patients underwent tissue expansion for breast reconstruction between 1980 and 1986. The cases were reviewed, and preoperative risk factors, postoperative complications, and aesthetic results were assessed. Cigarette smoking correlated with a higher incidence of complications and unfavorable results. Similar correlations were found among patients with histories of significant medical disorders or alcohol abuse, although patient numbers were small in these categories. Subpectoral and suprapectoral placement of expanders yielded similar complication rates and aesthetic results. Surgical techniques contributing to improved aesthetic results are described.     

Achieving consistency in the lateral nasal osteotomy during rhinoplasty: an external perforated technique.

The lateral nasal osteotomy is an integral element in rhinoplasty. A reproducible and predictable technique for the lateral nasal osteotomy (when indicated) is a significant contributor to operative success. A variety of methods and instrumentation are used to produce lateral osteotomies; currently, the two different modes used most frequently are the internal continuous and external perforated techniques. A previously published study by the senior author detailed the benefits of the external perforated osteotomy after comparing the two different methods. This article describes the role of the external perforated osteotomy technique in reproducing consistent results in rhinoplasty with minimal postoperative complications.     

Postrhinoplasty nasal cysts and the use of petroleum-based ointments and nasal packing

Nasal cysts are rare complications of rhinoplasty, and numerous theories exist regarding their cause. The term "paraffinoma" has been used to describe cyst formation observed after topical antibiotic ointment application with nasal packing in the immediate postoperative period. Such complications are rare but may occur because of the inherent properties of the agent used or a lack of meticulous technique (in the placement of incisions and nasal packing). Three cases of postrhinoplasty cysts with a variety of presentations, including incidental intraoperative findings, bilateral medial canthal masses, and a draining dorsal cyst, are described. Although such cysts are uncommon, techniques to prevent these unwanted sequelae should routinely be used, with the judicious application of non-petroleum-based topical antibiotic preparations.     

Importance of the nasal-to-cervical relationship to the profile in rhinoplasty surgery

There is general agreement that when discussing surgery with the prospective rhinoplasty patient, one may also include discussion of the chin because of the important interrelationship between these two regions. It is apparent that on the profile-lateral view, the four prominences-the forehead, nose, chin, and neck-balance and complement one another. The cervical region, the fourth dimension, was examined to estimate the aesthetic significance of the nasal-to-cervical relationship and to determine the implications to rhinoplasty surgery.Part I of the study was a survey to test the hypothesis that the cervical region affects the perceived impression of the nose. Four standard facial-profile black-and-white photographs were chosen to represent varying degrees of nasal dorsum hump and cervical ptosis problems. Using computer-altering software, only the cervical regions were altered to create a pair of photographs for each of the four profiles: one with a youthful-looking non-ptotic cervical region, the other with a ptotic aged-looking cervical region. Raters were asked to give their first-impression opinions of which nose subjectively appeared "better." Raters consistently (84 percent of the time) chose the nose on the faces with the less ptotic neck as being better. Therefore, a less ptotic neck improved the perceived appearance of the nose.Part II was a retrospective chart review of the rhinoplasty patients of a single surgeon by independent raters. To estimate the aesthetic significance of the nasal-to-cervical relationship, the proportion of patients undergoing rhinoplasty surgery who could have potentially benefited from a youth-restoring neck procedure was determined. Criteria originally described by Ellenbogen and Karlin for judging the results of youth-restoring neck procedures were used as relative indications for neck surgery. An average of 27.2 percent of the patients did not have visible criteria and therefore by definition had relative indications for neck-rejuvenating procedures when undergoing rhinoplasty surgery. As demonstrated in part I of the study, improving the neck could improve the perceived results of the rhinoplasty.Part III of the study validated the Ellenbogen and Karlin criteria. The present authors found that the original criteria were probably based on female patients, that male and older patients had more indications for surgery, and that there was significant interrater agreement with the youthful criteria.In summary, the authors established that a strong nasal-to-cervical relationship exists whereby the perceived appearance of the nose is affected by the neck. The significance of this relationship to rhinoplasty surgery was determined, and it was found that more than 27 percent of rhinoplasty patients could obtain better perceived nasal results with a concomitant neck-rejuvenating procedure. Consequently, discussing neck-rejuvenating procedures with the rhinoplasty patient is valuable.     

Rhinoplasty in the African-American patient

Because of the increasing popularity of rhinoplasty in the African-American patient, we delineate how a rhinoplasty surgeon can perform this challenging technique to obtain uniform and consistent results. First, we address how one can appreciate and analyze the various aesthetic concepts of beauty and the unique anatomic characteristics of the African-American nose. Second, we present a pragmatic, systematic analysis of the African-American nose. Last, we describe the techniques consistently used to modify the African-American nose while achieving or maintaining facial harmony using the open approach to rhinoplasty. Specific case analyses are presented to demonstrate utilization of the technique.     

The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty

One of the most common problems affecting both the primary and secondary rhinoplasty patient is deformity of the alar rim. Typically, this deformity is caused by congenital malpositioning, hypoplasia, or surgical weakening of the lateral crura, with the potential for both functional and aesthetic ramifications. Successful correction and prevention of alar rim deformities requires precise preoperative diagnosis and planning. Multiple techniques of varying complexity have been described to treat this common and challenging problem.Over the past 6 years (1994 through 2000), the authors have employed a simple technique in 123 patients for alar retraction that involves the nonanatomic insertion of an autogenous cartilage buttress into an alar-vestibular pocket. Among the 53 patients who underwent primary rhinoplasty in this study, 91 percent experienced correction or prevention of alar notching or collapse. However, correction was achieved for only 73 percent of the patients who underwent secondary rhinoplasty; many of whom had alar retraction secondary to scarring or lining loss. In patients with moderate or significant lining loss or scarring, a lateral crural strut graft is recommended. The alar contour graft provides the foundation in the patient undergoing primary or secondary rhinoplasty for the reestablishment of a normally functioning external nasal valve and an aesthetically pleasing alar contour. This article discusses the anatomic and aesthetic considerations of alar rim deformities and the indications and the surgical technique for the alar contour graft.     

Rhinoplasty and endoscopic surgery for functional and inflammatory nasal/sinus disorders

The rhinoplastic surgeon when faced with nasal sinusitis has traditionally delayed aesthetic treatment of the nose, referring the patient to the ear, nose, and throat consultant until complete resolution of the inflammatory condition. Often, under such a scenario, the patient found the ear, nose, and throat procedure to be a traumatic experience that discouraged further surgery of an aesthetic nature. The advent of functional endoscopic sinus surgery has significantly modified the management of paranasal sinus disorders. This minimally invasive, sophisticated procedure can easily be combined with rhinoplasty. More recently, an endoscopic approach has been advocated for management of the septum and lower/middle turbinates. The authors call this functional endoscopic nasal surgery. Functional endoscopic nasal surgery allows a clearer view of the operative field (septum and turbinates), a more accurate correction of nasal obstruction, and better control of bleeding. Thus, endoscopic techniques permit the treatment of functional and inflammatory nasal disorders in a single stage, along with aesthetic improvement. Only the patient with severe sinusitis is unsuitable for combined therapy. The authors present their experience based on 72 consecutive cases of combined functional endoscopic sinus surgery/functional endoscopic nasal surgery with aesthetic rhinoplasty. Complications were minimal and functional failures were limited to 4 percent, whereas aesthetic outcomes remained uncompromised.     

Valvular obstruction of the nasal airway.

Valvular nasal obstruction may occur in the postoperative rhinoplasty patient. One may anticipate a dropping of the tip, from residual redundant or inelastic skin, in some older patients with long noses. Measures to correct (or avoid) this may be undertaken at the time of the primary rhinoplasty. However, an overcorrection may be necessary if there is much redundant skin. Discretion may indicate the need for a secondary procedure. Lateral wall valving is unusual-but it may occur in the long, high, thin nose (where a suggestion of this action may be observed preoperatively). Maintenance of continuous cartilage along the alar rim, at the time of alar cartilage resection, appears to be important in prevention of postoperative valvular obstruction in these few patients.     

An algorithm for correcting the asymmetrical nose

Correction of the twisted nose forms the watershed of aesthetic and reconstructive rhinoplasty, combining and requiring elements of each. Faced with this formidable task, surgeons have fashioned a great number of techniques, many of which rely for their cardinal step on cutting, fracturing, or scoring the dorsal septal strut. While highly satisfactory results have been achieved with these methods, the constant problem of loss of dorsal support remains. It is possible in many cases to align the crooked nose while leaving intact osteocartilaginous dorsal support. The key determination to be made is the preoperative aesthetic balance, itself a product of bridge height and nasal base size. Once nasal aesthetics have been established, the algorithm proceeds as follows: First, resect the dorsum in the area of the deviation until the dorsal septal edge is sufficiently close to the midline to allow camouflage of the remaining asymmetry. Second, perform the septal resection necessary for the airway, preserving a continuous dorsal strut. Third, augment according to (a) the support needed for the dorsum, middle vault, columella, and tip and (b) the aesthetic balance that must be restored.     

Rhinoplasty: a CT-scan analysis

In order to assess the postoperative consequences of various rhinoplasty techniques, CT scans were done in 35 patients having a rhinoplasty operation. This series can be subdivided into those having preoperative and postoperative scans at both 2 days and 6 months (15 patients), a postoperative scan only at 48 hours (10), or a long-term postoperative scan at a mean of 12 months (10). Preoperative analysis indicates that a wide variation exists in lateral nasal wall anatomy and angulation. Surgically, the lateral nasal walls undergo limited medial movement, with tilt a significant component. Postoperatively, extensive remodeling can occur, and virtually all osteotomies are healed by osseous union at 6 months. Future application of CT scans in severely deviated noses may be justified.     

The true hanging columella: simplified diagnosis and treatment using a modified direct approach

An imbalance between the alar rim and the columella border can be a disturbing aesthetic deformity. If the cause is a pseudohanging columella, the therapy should be directed to the alar rims. When the deformity is a true hanging columella with unusually wide medial crural cartilages, balance can be restored by excising a C-shaped crescent of cartilage from the cranial border of the medial crura of the alar cartilages in a direct approach. This condition was present in approximately 15 percent of the patients reviewed. The treatment of a true hanging columella adds a subtle beneficial enhancement to the results of a rhinoplasty. The authors describe a simplified diagnostic method and present their experience treating the true hanging columella using a modified "direct approach" through a closed endonasal rhinoplasty.     

Endoscopically assisted, intraorally approached corrective rhinoplasty.

In the field of facial surgery, operations that require guesswork can result in unexpected complications. One example of such "blind" facial surgery is the lateral osteotomy procedure in corrective rhinoplasty. In most conventional corrective rhinoplasties, the postoperative results of a lateral osteotomy can be controlled by the surgeon's visual perception or manual dexterity; therefore, an experienced surgeon is indispensable in such elaborate operations. Until now, reports have focused on the endoscopic approach through the nasal dorsum or septum through the nostril. However, because of the difficulty in handling the endoscope with osteotomy instruments, it is considered difficult to perform a precise lateral osteotomy procedure using that approach. The authors think the intraoral endoscopic approach should be considered a viable alternative in corrective rhinoplasty.Through small, bilateral gingivobuccal incisions, both the piriform apertures and nasal bones can be easily exposed, and the exact level of the lateral osteotomy can be confirmed directly under the endoscope. The lateral osteotomy is made simply with a reciprocating saw, and symmetrical cutting can be ascertained during the operation. Sometimes, a particular osteotomy level or the proper repositioning of osteotomed segments can be readily evaluated with assistance from the endoscope during the operation. Eleven cases using this procedure were performed over the past 3 years. These endoscopic repairs for a deviated nose were quite helpful for visual confirmation and accurate correction. No complications occurred when using the endoscope with this procedure.     

Four common anatomic variants that predispose to unfavorable rhinoplasty results: a study based on 150 consecutive secondary rhinoplasties

A retrospective study was conducted of 150 consecutive secondary rhinoplasty patients operated on by the author before February of 1999, to test the hypothesis that four anatomic variants (low radix/low dorsum, narrow middle vault, inadequate tip projection, and alar cartilage malposition) strongly predispose to unfavorable rhinoplasty results. The incidences of each variant were compared with those in 50 consecutive primary rhinoplasty patients. Photographs before any surgery were available in 61 percent of the secondary patients; diagnosis in the remaining individuals was made from operative reports, physical diagnosis, or patient history. Low radix/low dorsum was present in 93 percent of the secondary patients and 32 percent of the primary patients; narrow middle vault was present in 87 percent of the secondary patients and 38 percent of the primary patients; inadequate tip projection was present in 80 percent of the secondary patients and 31 percent of the primary patients; and alar cartilage malposition was present in 42 percent of the secondary patients and 18 percent of the primary patients. In the 150-patient secondary group, the most common combination was the triad of low radix, narrow middle vault, and inadequate tip projection (40 percent of patients). The second largest group (27 percent) had shared all four anatomic points before their primary rhinoplasties. Seventy-eight percent of the secondary patients had three or all four anatomic variants in some combination; each secondary patient had at least one of the four traits; 99 percent had two or more. Seventy-eight percent of the primary patients had at least two variants, and 58 percent had three or more. Twenty-two percent of the primary patients had none of the variants and therefore would presumably not be predisposed to unfavorable results following traditional reduction rhinoplasty. This study supports the contention that four common anatomic variants, if unrecognized, are strongly associated with unfavorable results following primary rhinoplasty. It is important for all surgeons performing rhinoplasty to recognize these anatomic variants to avoid the unsatisfactory functional and aesthetic sequelae that they may produce by making their correction a deliberate part of each preoperative surgical plan.