Surgical approach
A suitable premedication may be administered the night before surgery and/or the morning of surgery to facilitate a state of relaxation. At the time of surgery, the nose is topically decongested with pledgets or ribbon gauze. If the surgery is to be performed with awake sedation, then topical anesthetic is also applied. Local anesthetic is injected sparingly into the proper surgical planes in the standard fashion for septoplasty and rhinoplasty. A large volume of anesthetic is avoided to prevent distortion of nasal contour. A total of no more than 7-8 mL of local anesthetic is sufficient to produce profound vasoconstriction and nasal anesthesia. Direct injection into the membranous septum is avoided because this may distort the columella. No anesthetic is injected along the nasal dorsum in order to prevent distortion.
The vast majority of patients requiring a significant reduction or increase in nasal projection require either a delivery approach (bilateral chondrocutaneous flap) or an open approach. Making bilateral intercartilaginous incisions, connecting the incisions over the anterior septal angle, and extending them into a high partial transfixion incision initiates the delivery approach. Marginal incisions are made along the caudal margin of the lateral crus. The lateral crus then is delivered into the nares providing exposure for direct surgical modification.
In the external rhinoplasty approach, an inverted-V transcolumellar incision is made at the level of the midcolumella. In order to provide support to the scar, the incision is made overlying the caudal margin of the medial crura where they lie just beneath the skin. The transcolumellar incision is connected to bilateral marginal incisions via marginal columellar incisions placed approximately 1-2 mm behind the columellar rim. Care must be taken to make incisions perpendicular to the skin edge to avoid beveling, which may result in a trap door deformity. The transcolumellar flap then is elevated with scissors over the medial crura and the incision is completed. In this way, inadvertent damage to the medial crura is avoided.
Using Converse scissors and 3-point countertraction, the flap is elevated in an immediately supraperichondrial plane over the lower lateral crura, completing the marginal incisions. In the midline, the anterior septal angle is identified and dissection is carried out again in a supraperichondrial plane over the middle nasal vault, exposing the upper lateral cartilages. Under direct vision using an Aufricht retractor, the periosteum of the nasal bones is incised and elevated to the nasion in the midline. Care is taken to not undermine the periosteum of the sidewalls of the bony nasal pyramid because this structure may provide support for osteotomies. With this exposure obtained, modification of the nasal tip, middle vault, and bony nasal pyramid can be achieved.
Correction of overprojection
Correction of an overprojecting nose involves the following surgical principles:
- Retroprojection via reduction of tip support mechanisms
- Reduction of overdeveloped anatomic structures
- Normalization of adjacent anatomic structures
Many of the incisions and maneuvers used in the standard surgical approaches weaken tip support mechanisms. The resultant retroprojection can be desirable in the overprojected nose and, in that case, can be viewed as an additional benefit of the surgical approach. A complete transfixion incision results in immediate retroposition of the nasal tip when incorporated into the surgical exposure. When the nasal tip is retroprojected, flaring of the alar sidewall and widening of the nasal base may result. Aware of this potential change, the surgeon can consider the need for alar base reduction procedures at the time of surgery.
In the tension nose deformity, reducing the anatomic component or the components causing the pedestal effect on the nasal tip corrects overprojection. Initially a transfixion incision is performed, allowing inspection of the posterior septal angle and nasal spine. Through this incision, the posterior septal angle can be reduced directly. If the nasal spine also is overdeveloped, bone-biting rongeurs or an osteotome can be used to reduce the nasal spine and thereby reduce the posterior septal angle. This access also allows excision of caudal or membranous septum, if indicated.
Once full surgical exposure has been obtained, the anterior septal angle can be evaluated and reduced, completing deprojection of the pedestal. The alar cartilages may be normal, hypertrophied, or underdeveloped in the tension nose deformity. Therefore, reprojection of the nasal tip usually is required after deprojection of the pedestal. Placement of a columellar strut and tip grafting, if indicated, can achieve reprojection.
Alar cartilage overdevelopment also results in overprojection. Addressing the hypertrophied component or the components of the alar cartilage (ie, the medial, lateral, or intermediate crus) corrects overprojection. Interrupted strip techniques with suture reconstitution may be required to reduce the overdeveloped component. Lateral crural overlay involves excision of a strip of lower lateral crus lateral to the domes. The vestibular mucosa must be elevated from the undersurface of the lower lateral crura and preserved. The medial portion of the lower lateral crus then overlaps and is sutured to the lateral aspect of the lower lateral cartilage. Care must be taken in performing this technique because symmetry is critical, and tip rotation is also achieved.
Vertical dome division can also be used when deprojection is desirable. The dome is divided and excess cartilage medial to this incision is removed. Elevating the vestibular skin from the undersurface of the cartilage preserves the skin. The cartilage may then be reconstituted with suture. This technique should be used with extreme caution in thin-skinned patients, and tip grafts are generally required for camouflage. Vertical dome division techniques also can result in iatrogenic overprojection. This generally occurs from overaggressive attempts at lateral crural steal using the Goldman technique and its variants. The overprojecting cartilage, which usually is the medial crura, is reduced, and appropriate projection is restored.
Correction of underprojection
Lengthening of the central limb of the tripod can be accomplished in a variety of ways. Domal binding sutures can be designed to incorporate a larger segment of lateral than medial crus. The result is a medial shift of a portion of the lateral crus. Lateral crural steal can also be accomplished by vertical dome division with suture reconstitution of the medial and lateral crura to preserve domal integrity. Placement of a columellar strut also strengthens the central limb of the tripod and augments nasal projection.
A columellar strut is placed by developing a pocket between the medial crura, placing the graft, and fixing it with suture. Ideally, septal cartilage is harvested, and the graft typically measures 8-12 mm long, 3-4 mm wide, and 1-2 mm thick. The columellar strut also can correct asymmetries caused by buckling of the medial or intermediate crura and can be used to augment columellar show. When developing the pocket between the medial crura, care must be taken to leave soft tissue between the graft and the nasal spine. This prevents the strut from shifting to one side of the spine, which can cause deviation of the tip. Soft tissue also prevents the strut from shifting back and forth over the spine, which may produce an annoying click.
If significant divergence of the medial crural footplates is present, resecting intercrural soft tissue and suturing the medial crural footplates together can augment tip support. This technique converts some of the horizontal width to vertical height. Placement of septocolumellar sutures to affix the medial crural–columellar strut complex to the caudal septum reconstitutes this major tip support and also can provide some tip projection.
Transdomal suturing results in refinement of the nasal domes and also may augment projection slightly. Transdomal sutures can reorient the alar cartilages, preserve or augment tip support, and, depending on placement, can add 2-3 mm of stable projection to the tip. Individual horizontal mattress sutures can be placed in each dome to achieve narrowing, followed by an interdomal suture to set the width between the domes. Alternatively, a single transdomal suture incorporating a horizontal mattress stitch in each dome can be used. In either case, place the horizontal mattress suture through the dome so that a wider amount of cartilage is included on the caudal pass than on the cephalic pass. The result is that the caudal cartilage edge usually leads the cephalic edge when the suture is tightened. If the caudal edge does not lead the cephalic edge, excision of a small cephalic wedge with suture reapproximation usually is corrective.
When significant tip projection is needed, tip grafting techniques can be invaluable. Tip grafts can also serve to alter tip contour. Tip grafts are placed in carefully developed subcutaneous pockets in endonasal approaches and stabilized with sutures in open approaches. When placed endonasally, tip grafts (single or laminated) lie in intimate subcutaneous pockets. Exact sculpturing of their size and shape is mandatory. Bilateral marginal incisions beneath the anatomic dome area facilitate the careful pocket creation and render final positioning and stabilization of the graft easier than if only one incision is used.
Tip grafts are carved in triangular, trapezoidal, or shieldlike shapes with carefully beveled edges to avoid any contour irregularities. Grafts are placed to accentuate favorable tip-defining points and highlights, while imparting a more natural appearance to tips with congenital or postsurgical irregularities. Suture fixation of the graft may be necessary if undermining is developed widely in a primary delivery or open approach method.
In the open approach, all tip grafts are stabilized with suture fixation. When minimal additional projection is needed, a cap graft can be used. This trapezoidal piece of cartilage can be carved with carefully beveled edges and sutured in place overlying the domes. The cap graft also provides camouflage when vertical dome division has been performed in the thin-skinned patient. When significant projection is required, the sutured-in-place shield graft is needed. Typically harvested from septal cartilage, the shield graft usually is 8-15 mm long, 8-12 mm wide, and 1-3 mm thick.
When auricular cartilage is used, the graft should be double-layered to provide strength. The shield graft is thicker at the leading edge and thinner at the base. It is sutured to the caudal margins of the medial and intermediate crura and usually overrides the existing domes by 1 or 2 mm. If the tip graft is required to project a greater distance above the domes, a buttress graft is used to support the leading edge of the shield graft. The additional support from this technique also may be useful when the tip graft is harvested from auricular cartilage, which is more pliable, or when the patient has a very thick skin and soft tissue envelope. The buttress graft is a trapezoidal or rectangular piece of cartilage that is sutured to both the underlying domes and the shield graft.
In revision rhinoplasty, a weakened and overly resected cartilage framework may be encountered. The resultant deprojection and superior rotation can be addressed through structural grafting techniques such as the dynamic adjustable rotation tip (DART) or the caudal extension graft. The DART technique is performed through an open rhinoplasty approach, and grafts ideally are harvested from septal cartilage. Two septocolumellar interpositional grafts (SCIGs) are placed between the septum and upper lateral cartilages and are similar to long spreader grafts.
A columellar strut is sutured between the medial crura and also sutured to the SCIGs. Sliding the SCIGs along the quadrangular cartilage in an anterior-posterior fashion determines the final position of the tip complex. Sutures then are used to affix the tip complex in the desired position. This maneuver allows the surgeon to position the tip complex in the sagittal plane and to select the desired inferior tip rotation and resultant tip projection.
A caudal extension graft can be used to correct a variety of deformities, including a retracted columella, a short nose, and an overrotated tip. This graft also can increase tip support and projection. The graft usually is harvested from septal cartilage and is sutured to the caudal margin of the nasal septum. It then is secured between the medial crura, achieving desired tip projection. The key to the caudal extension graft is precise midline placement.
Plumping grafts can be used to address a variety of deformities. When placed overlying the nasal spine in the lower columella, plumping grafts may improve the appearance of a retracted columella and open up an acute nasolabial angle. This result is accomplished either by developing a midcolumellar pocket in the open rhinoplasty approach or by making a low lateral columellar incision in endonasal approaches. Multiple pieces of septal or auricular cartilage are placed for augmentation. Nasal base support is increased when grafts are placed below the medial crural footplates.
Enhancing the supratip break can achieve the illusion of projection. The cartilaginous dorsum can be reduced incrementally to redefine the relationship of the supratip to the tip, thereby allowing the tip to project 2-3 mm above the supratip region. If preoperative tip projection is inadequate, however, attempts to overreduce the supratip cartilaginous dorsum in order to produce pseudoprojection of the tip are inadvisable.
Maintenance of projection
If the preoperative projection of the tip is normal and adequate, lowering the cartilaginous dorsum into proper alignment achieves a satisfactory aesthetic appearance, provided that no loss of tip support occurs during the operative or postoperative period. Preserving the major and minor tip support structures decreases this likelihood, whereas their sacrifice, without compensatory reestablishment of support, inevitably leads to eventual tip ptosis.
Postoperative details:
The care of the patient is directed toward comfort, reduction of swelling and edema, patency of the nasal airway, and compression stabilization of the nose. Topical adhesive is applied and tape or Steri-Strips placed in graduated strips. In this manner, slight compression of the skin and soft tissue envelope onto the underlying nasal skeleton is achieved. A long strip of tape or Steri-Strip is then placed underneath the nasal tip to provide support and is carried onto the nasal sidewalls. The tape is then pinched on both sides to produce compression of the nasal tip. The final step is application of a nasal splint covering only the area between the lateral osteotomies. The splint can be made of plaster, aluminum, or thermoplast. Casting is important for reducing edema and to allow final moulding of the nasal bones.
The patient is instructed to keep the head elevated and avoid any lifting or strenuous activity. Oral glucocorticoids are given to reduce edema. Oral decongestant therapy may be helpful. Nasal saline is used to irrigate the nose and prevent dryness and crusting. A detailed list of instructions is provided to the patient. The important aspects of care are emphasized. Prevention of trauma to the nose is the most important consideration.
A follow-up visit is scheduled 5-7 days postoperatively, during which the cast and intranasal splints are removed and nasal secretions are suctioned. If permanent transcolumellar sutures are used, these are removed at 3-5 days postoperatively. An important consideration is gentle removal of the tape and splint. Blunt dissection of the nasal skin from the overlying splint is performed with a dull instrument or cotton applicator to avoid disturbing or tenting up the healing skin.
Failure to follow this policy may lead to disturbance of the newly forming subcutaneous fibroblastic layer over the nasal dorsum, with additional unwanted scarring and even abrupt hematoma. The nose is then retaped to facilitate compression and redrapage of the skin and soft tissue envelope to the underlying nasal skeleton. This taping is continued for at least 2 weeks postoperatively but can be extended depending on the amount of residual edema. The next visit is approximately 3 weeks postoperatively, and another visit is scheduled approximately 3-4 weeks later. Initial postoperative photographs can be taken if desired.
Follow-up care:
When prolonged tip edema is present, injection of small volumes of triamcinolone acetonide (Kenalog, 10 mg/mL) into the region of the supratip may be beneficial. Use this treatment very conservatively to avoid atrophy of the tissue, particularly because the supratip edema usually resolves given additional time. A tuberculin syringe with a 30-gauge needle is used to inject, generally less than 0.2 mL, into the subdermal plane. The patient should be monitored periodically for at least one year to document the procedure, to monitor the healing process, and to detect impending complications for intervention.
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