Escolar Documentos
Profissional Documentos
Cultura Documentos
PART V
AESTHETIC SURGERY
CHAPTER 48 RHINOPLASTY
JEFFREY E. JANIS, JAMIL AHMAD, AND ROD J. ROHRICH
INTRODUCTION
Rhinoplasty is challenging. Over the past 20 years, the trend has
shifted from ablative techniques involving reduction or division of the
osseocartilaginous framework to techniques that conserve native
anatomy. Cartilage sparing suture techniques and augmentation of
deficient areas to correct contour deformities and restore structural
support are commonly employed.1 The rhinoplasty surgeon must
understand the underlying anatomy and have the ability to perform
nasofacial analysis to determine the operative plan and the training to
execute techniques that manipulate bone, cartilage, and soft tissue.
These skills are augmented by an aesthetic eye in order to produce a
result that blends harmoniously with the rest of the face.
NASAL ANATOMY
The nose consists of external skin and soft tissue, underlying
osseocartilaginous framework, and ligamentous support. Familiarity with
the native morphology and potential variations of each structure is
essential. Furthermore, the dynamic interplay between these components
must be appreciated.
Skin
The nasal skin is not uniform; its thickness, mobility, and sebaceous
character vary along the length of the nose.2 The skin of the upper two-
thirds is thinner, averaging 1,300 µm versus the lower one-third, which
averages 2,400 µm.3 The upper two-thirds is also more mobile and less
sebaceous than the skin of the nasal tip. It is important to note that a
straight dorsum is actually produced by the underlying convexity in the
osseocartilaginous framework combined with the aforementioned
variation in dorsal skin thickness.
Skin character also varies between ethnic subpopulations.4-6 Even
minor alterations of the underlying framework will be visible
through thin skin, whereas thicker skin will tend to obscure the
underlying details and require more aggressive manipulation in
order to achieve the desired result.
Muscle
While there are several muscles in the nose, two muscles are
particularly important in rhinoplasty—the levator labii alaeque nasi and
the depressor septi nasi. The levator labii alaeque nasi assists in
maintaining the patency of the external nasal valve, while the depressor
septi nasi acts to shorten the upper lip and decrease tip projection
FIGURE 48.8. The face is divided into thirds, using horizontal lines
tangent to the hairline, brow, nasal base, and chin.
7. The alar rims are examined for symmetry. They should normally
flare slightly outward in an inferolateral direction (Figure 48.14).
8. The tip is assessed by drawing two equilateral triangles with their
bases opposed (Figure 48.15). The supratip break, tip-defining points, and
columellar-lobular angle serve as landmarks. If these triangles are
asymmetric, the patient will likely require tip modification.
9. The final assessment on frontal view is of the outline of the alar rims
and the columella. Normally, this outline should resemble a seagull in
gentle flight. If the angles are too steep, the patient likely has an increased
infratip lobular height. Conversely, if the angle/curve is too flattened, it is
likely the patient has decreased columellar show, which may require
columellar and/or alar rim modification (Figure 48.16).
FIGURE 48.9. The ideal nasal length is equivalent to the stomion- to-
menton distance. A, ala; M, menton; R, radix; S, stoma; T, tip.
FIGURE 48.10. The ideal lower lip position is 2 mm behind a vertical
line dropped from a point half the ideal nasal length along the natural
horizontal facial plane.
10. The basal view of the nose is examined focusing on the outline of
the nasal base and the nostrils themselves. The outline of the nasal base
should describe an equilateral triangle with a lobule-to-nostril ratio of 1:2
(Figure 48.17). The nostril itself should have a teardrop geometry, with the
long axis oriented in a slight medial direction (from base to apex).
FIGURE 48.11. Symmetry is determined by drawing a vertical line
from the midglabellar area to the menton.
FIGURE 48.12. The curvilinear dorsal aesthetic lines extend from the
supraorbital ridges to the tip-defining points.
FIGURE 48.13. A. The normal alar base width equals the intercanthal
distance, or the width of one eye. B. The bony base should be
approximately 80% of the alar base width.
11. Attention is turned to the lateral view, beginning with analysis of
the nasofrontal angle. This angle connects the brow and nasal dorsum
through a soft concave curve. The apex of this angle (radix) should lie
between the supratarsal fold and the upper lid lashes, with the eyes in
primary gaze. The nasofrontal angle can vary between 128° and 140°, but
is ideally approximately 134° in females and 130° in males.
12. It is important to note that the perceived nasal length and tip
projection can be altered by the position of the nasofrontal angle. For
instance, the nose appears longer if the nasofrontal angle is positioned
more anteriorly and superiorly than normal. In this instance, the nasofacial
angle (as defined by the junction of the nasal dorsum with the vertical facial
plane) is decreased and the tip projection will appear diminished (yellow
line). Conversely, the nose can appear shorter if the nasofrontal angle is
positioned too posteriorly and/or inferiorly. In this case, the tip may also
appear more projecting (red line; Figure 48.18). Ideally, the nasofacial
angle should measure 32° to 37°.
13. While still analyzing the lateral view, tip projection is addressed.
This can be done in two ways. The first is to draw a horizontal line from the
alar-cheek junction to the tip of the nose. The distance between these
points should equal two things: (1) the alar base width, and (2) 0.67 × R-
T (radix-to-tip) (Figures 48.19A and B). The second way to assess tip
projection is to examine how much of the tip lies anterior to a vertical line
tangent to the most projecting part of the upper lip vermillion. If 50% to
60% of the tip lies anterior to this line, projection is considered normal. If
the tip projection is outside of these proportions, it likely will require tip
modification (Figure 48.20).
FIGURE 48.14. The alar rims should flare outward inferolaterally.
14. The dorsum is analyzed by drawing a line from the radix to the tip-
defining points. In women, the ideal aesthetic nasal dorsum should lie
approximately 2 mm behind and parallel to this line, but in men, it should
approach this line to avoid feminizing the nose (Figure 48.21).
15. The degree of supratip break is also evaluated on the lateral view.
This break helps to define the nose and separate the tip from the dorsum.
A slight supratip break is preferred in women but not in men.
16. The degree of tip rotation is assessed by evaluating the nasolabial
angle, which is the angle formed between a line coursing through the most
anterior and posterior edges of the nostril and a plumb line dropped
perpendicular to the natural horizontal facial plane (Figure 48.22). This
angle is usually 95° to 100° in women and between 90° and 95° in men.
17. The nasolabial angle is often confused with the columellar-lobular
angle, which is formed at the junction of the columella with the infratip
lobule (Figure 48.23). This angle is normally 30° to 45°. A prominent caudal
septum can cause increased fullness in this area, which can give the illusion
of increased rotation, despite a normal nasolabial angle.
FIGURE 48.15. Tip assessment is performed by analyzing two
equilateral triangles with opposing bases.
FIGURE 48.16. The outline of the alar rims and columella should
resemble a “seagull in gentle flight.”
FIGURE 48.19. A. Tip projection should equal alar base width. B. Tip
projection should also equal 0.67 × R-T (radix-to-tip).
FIGURE 48.20. About 50% to 60% of the tip should lie anterior to a
vertical line tangent to the most projecting part of the upper lip vermillion.
Inferior Turbinoplasty
An inferior turbinoplasty is performed in those patients with inferior
turbinate hypertrophy causing symptomatic nasal airway
obstruction.11,16,17 In most cases, outfracture of the inferior
turbinate is adequate. With more significant inferior turbinate
hypertrophy, submucous morselization of the turbinate bone and
submucous resection of the anterior one-third to one-half of the inferior
turbinate may be required. Submucous resection technique begins with
the development of medial mucoperiosteal flaps, which exposes the
conchal bone. The anterior portion of the conchal bone is resected, while
the posterior portion is preserved to avoid bleeding complications. The
flaps are replaced after this resection without the need for suture repair.
Cephalic Trim
Indications for a cephalic trim of the LLCs include the need for tip
rotation, medialization of the tip-defining points, and/or the tip requiring
better refinement and definition as in the case of the boxy or bulbous
tip.42-44 A caliper is used to measure a 6 mm rim strip of the caudal
margin of the LLC that is to be preserved. Subsequently, the cephalic
portion of the middle and lateral crura is resected and preserved for
possible use as a graft later in the case.
Lower Lateral Crural Turnover Flap
A lower lateral crural turnover flap is a useful technique to address
paradomal fullness while providing additional support to the LLCs (Figure
48.26).21 It is beneficial for deformities, weakness, and collapse of the
lower lateral crura and can also be used to improve lower lateral crural
strength during tip reshaping.
Spreader Grafts and Autospreader Flaps
Spreader grafts are extraordinarily versatile and can be used to help
stent open the internal valve, to stabilize the septum, and to preserve or
enhance the dorsal aesthetic lines (Figure 48.27).45,46 These grafts,
usually obtained from septal cartilage, are fashioned to measure
approximately 25 to 30 mm by 3 mm. They can also be made longer and
placed in such a way as to project past the anterior septal angle,
effectively lengthening the nose. They can also be positioned more
anteriorly (i.e., visible) along the septum in order to recreate stronger
dorsal aesthetic lines or can be positioned lower (i.e., invisible) for septal
support or internal valve stenting. The grafts are secured with 5-0 PDS in
a horizontal mattress fashion.
FIGURE 48.27. Spreader grafts can be used to stent open the internal
nasal valve, stabilize the septum, or preserve or enhance the dorsal
aesthetic lines.
4. Fibrous connections between ULCs and LLCs
5. Abutment with the pyriform aperture
6. Anterior septal angle
7. Skin and soft-tissue thickness and availability
Alteration of any of these anatomic structures can result in incremental
changes in tip projection. An algorithmic approach to tip refinement
includes the use of cephalic trim, nasal tip suture techniques, and cartilage
grafting (Figure 48.28).
Nasal Tip Sutures. Nasal tip suture techniques can reliably produce
an increase of 1 to 2 mm of tip projection.42-44,48-53 The choice of suture
material is surgeon dependent, though the underlying premise is to select
a material that will hold the cartilage in its altered position long enough to
allow for the natural fibrotic reaction to solidify the result.
There are four general types of techniques used to alter projection:
• Medial crural
• Medial crural-septal
• Interdomal
• Transdomal (intradomal)
Medial crural sutures can be used to unify the medial crura of the LLCs
and to rectify flaring of the medial/middle crura, thereby effecting a limited
increase in projection (Figure 48.29). They are also frequently used to help
stabilize a columellar strut. Medial crural-septal sutures alter both
projection and rotation by anchoring the medial crura to the caudal septum.
Interdomal sutures can increase both tip refinement and tip projection.
They serve to narrow the interdomal distance by approximating the
medial/middle crura. Sutures are placed in mattress fashion and can be
tightened to a variable degree in order to achieve the desired result (Figure
48.30).
Transdomal (or intradomal) sutures can also affect both tip refinement
and projection. These mattress-type sutures are placed across the dome of
the middle crura after hydrodissection of the underlying
mucoperichondrium from the cartilage in order to help prevent inadvertent
intranasal exposure of the suture (Figure 48.31). Knots are left on the
medial aspect of the dome and one end may be left long on each side,
which can be used to tie the transdomal sutures together (i.e., an
interdomal suture) in order to narrow the tip-defining points. It is
important, however, to avoid over-tightening of this suture, which will
result in an unnaturally sharp tip-defining point. They may also be placed
asymmetrically in order to correct anatomic differences that may exist from
side to side.
Columellar Strut Graft. The placement of a columellar strut is the
second step in the algorithm for tip refinement and projection.48 Usually
fashioned from septal cartilage, the strut can be placed in a “fixed” or a
“floating” fashion, depending on whether or not it is secured to the anterior
maxilla. Columellar struts can control columellar profile as well as support
tip projection. A pocket is dissected between the medial crura and the strut
is inserted. Its final position is set by gently retracting the medial crura
anteriorly by a double hook and gauging the desired amount of tip
projection. This configuration is temporarily stabilized with a transversely
placed 25G needle and then sutured into position by medial crural sutures
(described previously). Additional medial crural sutures can then be placed,
if necessary, to control medial crural flaring.
FIGURE 48.28. Algorithmic approach to tip refinement.
FIGURE 48.29. Medial crural sutures can unify the medial crura and
help stabilize the columellar strut. Medial crural-septal sutures anchor the
medial crura to the caudal septum and can alter both projection and
rotation.
Nasal Tip Grafts. Nasal tip grafts are the final step in the algorithm if
more tip projection or definition is desired after the preceding
maneuvers.48 These grafts may take several forms, but have a tendency to
become visible in the long term regardless of the specific type used. Tip
grafts are reserved for the patient in whom the prior, more predictable,
methods do not result in satisfactory tip refinement and projection. There
are three general types of tip grafts:
• Onlay tip grafts
• Infratip lobular graft
• Combination tip graft
The onlay tip graft is usually placed over the dome of the middle crura
and can be fashioned from any type of cartilage54,55; the cartilage obtained
from the cephalic trim harvest (if performed) works exceptionally well
(Figure 48.32).56
The infratip lobular graft is a shield-shaped graft used to increase
infratip lobular definition and projection.57,58 It is positioned with its
superior margin overlying the dome/tip-defining points and extends
inferiorly a variable distance (usually 10 to 12 mm). It is fashioned with
rounded graft edges in order to avoid a visible and palpable step-off (Figure
48.33).
FIGURE 48.32. The onlay tip graft is usually placed over the dome of
the middle crura.
FIGURE 48.33. The infratip lobular graft overlies the dome and
extends inferiorly a variable distance.
Altering Tip Rotation. In order to alter tip rotation, the existing
extrinsic forces stabilizing the tip at its current position must be released.
The first step is usually to perform a cephalic trim, which separates the
connection between ULCs and LLCs. Another technique is to resect a
variable amount of the caudal septum. This releases tension on the nasal
tip and allows for more cephalad rotation by transecting the fibrous
attachments of the medial crura and the caudal septum. This maneuver
can also affect tip projection. After the desired amount of tip rotation has
been achieved, its position is maintained with suture techniques (medial
crural-septal sutures) and/or a columellar strut or septal extension graft.
It may be necessary to perform a limited resection of nasal mucosa and
membranous septum in order to maintain proper nasal balance and
harmony when altering the amount of tip rotation.
FIGURE 48.34. The combination tip graft combines the onlay tip graft
and the infratip lobular graft.
Osteotomies
Several techniques exist in order to perform osteotomies, including
medial, lateral, transverse, and a combination of the above. These can be
performed via an external or internal approach.
Osteotomies are generally performed for the following reasons:
• To narrow the lateral walls of the nose
• To close an open roof deformity (after dorsal hump reduction)
• To create symmetry by allowing for straightening of the nasal bony
framework
Contraindications include patients with short nasal bones, elderly
patients with thin, fragile nasal bones, and patients with heavy
eyeglasses.59-66
Lateral osteotomies may be performed as “low-to-high,” “low-to-low,”
or a “double level” (Figure 48.35). Furthermore, they may be combined
with medial, transverse, or greenstick fractures of the upper bony
segment. Regardless of the technique used, however, it is paramount to
preserve Webster’s triangle. This bony triangular area of the caudal
aspect of the maxillary frontal process is necessary for a patent
airway. Preservation of this triangle prevents functional nasal
airway obstruction (Figure 48.36).
A step-off deformity is prevented by maintaining a smooth fracture
line low along the bony vault. The cephalic margin of the osteotomy
should not be higher than the medial canthal ligament, as the
thick nasal bones above this area increase the technical difficulty,
and it is possible to cause iatrogenic injury to the lacrimal system
with resultant epiphora.
A “low-to-high” osteotomy begins low at the pyriform aperture and
ends “high” medially on the dorsum and is generally used to correct a
small open roof deformity or to mobilize a moderately wide nasal base.
The nasal bones are then medialized by a gentle greenstick fracture along
predictable fracture patterns obtained based on nasal bone thickness.59-
61 Thicker nasal bones may require a separate superior oblique osteotomy
Our preference is to keep our patients on a liquid diet on the day of surgery
and then advance them to a soft regular diet the following day. Any foods
that require excessive lip movements, such as eating apples or corn on the
cob, should be avoided for 2 weeks after surgery.
During the first 2 weeks, nasal congestion is treated with the use of normal
saline nasal spray. The patient is encouraged to breathe through the mouth
if there is difficulty with air passage through the intranasal splints. Extreme
congestion should be treated with office suctioning.
The sutures and nasal splints are removed at the initial visit on
postoperative days 5 to 7. The nose (especially the tip) may appear swollen
and turned up and the tip may feel numb, but the patient is reassured that
both are expected and will resolve over several months. Normal sensation
usually returns within 3 to 6 months. The patient is instructed to avoid
letting anything, including eyeglasses, rest on the nose for at least 4 weeks.
During this time, glasses are taped to the forehead. Contact lenses may be
worn as soon as the swelling has diminished enough to allow easy insertion
(usually less than 5 to 7 days postoperatively).
The patient’s activity is restricted for 3 weeks postoperatively. Any contact
sports or activities that may cause direct trauma to the nose are prohibited
for at least 4 to 6 weeks after surgery. Although some noses look excellent
within 6 to 8 weeks, some may have persistent edema for up to 1 year.
After 3 to 4 weeks, however, the swelling will generally not be obvious to
anyone but the patient.
After the first postoperative visit, the patient returns for follow-up at 3 and
8 weeks after the operation and then at 3, 6, and 12 months
postoperatively.
REVISION RHINOPLASTY
Revision rhinoplasty offers a unique set of challenges. Cicatricial
tissue, altered or compromised vascularity, and distorted anatomy can be
major factors that alter the planning and execution. The septal cartilage
may have already been harvested, which creates the need for remote
cartilage harvest from locations such as the ear or rib.
In a 2009 survey of board-certified plastic surgeons and
otolaryngologists, the majority reported revision rhinoplasty was required
in less than 10% of patients.36 The underlying etiology that drives the
need for reoperation usually includes one or a combination of the
following:
1. Displaced anatomic structures
2. Undercorrection from an overconservative primary procedure
3. Overresection/overcorrection from overzealous surgery
In the lower third of the nose, the most frequent reasons for
reoperation include further tip refinement or correction of tip
asymmetries. In the middle third, a parrot beak or narrow mid vault
deformity is responsible for most revisions. In the upper third, it is
excessive dorsal reduction or dorsal irregularities that require revision.
From a functional point of view, persistent nasal airway obstruction
from excessive narrowing of the internal valve was previously the most
common reason for secondary rhinoplasty. Once we adopted the
component dorsum reduction technique with preservation of the ULCs and
placed spreader grafts when necessary, our incidence of internal valve
obstruction decreased.
The open approach is preferred when performing revision rhinoplasty
as it affords superior exposure of the underlying nasal framework, permits
accurate anatomic diagnosis, and facilitates complete correction.36
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