You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > COSMETIC SURGERY Rhinoplasty, Management of the Polly Beak DeformityArticle Last Updated: May 17, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Jennifer P Porter, MD, Clinical Associate Professor, Department of Otolaryngology - Head and Neck Surgery, Chevy Chase Facial Plastic Surgery Jennifer P Porter is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and Texas Medical Association Coauthor(s): Henry Daniel Sandel IV, MD, Staff Physician, Department of Otolaryngology Head and Neck Surgery, Georgetown University Hospital Editors: Daniel G Becker, MD, Clinical Associate Professor, Department of Otorhinolaryngology-Head and Neck Surgery, Division of Facial Plastics and Reconstructive Surgery, University of Pennsylvania; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David W Stepnick, MD, Associate Professor, Departments of Plastic Surgery and Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine; Vice President, University Otolaryngology-Head and Neck Surgery, Inc; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: errors in profile alignment, rhinoplasty complication, plastic surgery, nose job complication, parrot's beak, parrot beak deformity, supratip deformity, tip-supratip deformity, birdlike deformity INTRODUCTIONSection 2 of 11
  Polly beak deformity is a complication of rhinoplasty defined by the typical appearance of a dorsal nasal convexity resembling a parrot's beak. If during the intraoperative evaluation of the nose, a surgeon does not recognize the improper tip-supratip relationship that is the hallmark of this deformity, a polly beak occurs. In addition, polly beak deformity may develop because of the inability of a surgeon to precisely predict the ultimate healing of the nose. ProblemPolly beak deformity describes the postoperative deformity associated with fullness in the supratip that leads to a disproportionate relationship between the tip and the supratip. FrequencyThe incidence of polly beak deformity is not known; however, it is one of the more common complications of rhinoplasty. One study showed that 64% of patients presenting for revision rhinoplasty had a polly beak deformity. EtiologyTwo general categories of a polly beak deformity are described. Each can result as a consequence of 1 or more conditions.
During surgery, excess edema often obscures the deformity. After surgery, scar tissue can replace edema of the supratip. ClinicalPatients with a polly beak deformity are generally dissatisfied with the birdlike appearance of their nose. Many patients report that their nose was massively swollen after surgery and that they noticed the deformity after the swelling resolved. In the case of loss of tip support, patients notice that the nose initially looks fine but that it evolves into a deformed profile. A clear understanding of the support mechanisms for the nasal tip, maintaining them, and reconstructing disrupted elements of tip support are paramount to preventing the eventual settling of the tip that occurs when these mechanisms are disturbed. INDICATIONSSection 3 of 11
Most of the healing from a rhinoplasty procedure takes a full year to complete, though the nose continues to change over a lifetime. In general, the outcome should not be critically assessed until a year after surgery. Delaying treatment of a polly beak deformity for a year is prudent; this delay allows the normal healing process to occur. A delay or more than a year may be necessary in patients with thick skin. Secondary or revision rhinoplasty is indicated in patients who have an obvious deformity that will not heal in a satisfactory manner. Surgery is indicated in patients who have a soft-tissue polly beak that is unresponsive to steroid injection. RELEVANT ANATOMYSection 4 of 11
The supratip is defined as an area of thick skin cephalic ad to the nasal tip (see Image 1 and Image 3). The cartilaginous dorsal septum composed of quadrangular cartilage supports the supratip. The nasal tip is composed of lower lateral cartilages. The most anterior point of the nasal tip, eg, the junction of the lateral and intermediate crus, is known as the tip-defining point. Understanding the normal relationship of the tip and the supratip region is paramount to predict the outcome of rhinoplasty. The nose may be divided into horizontal thirds, with the upper one third composed of bone and the lower two thirds composed of cartilage (see Image 2). The thickness of skin varies according to the region of the nose. In the normal nose, the tip-defining point should be approximately 6-10 mm anterior to the dorsal septum (eg, supratip) to have a supratip break. The skin in the area of the supratip is thick; take this into account when aligning the patient's profile. In men, a straight-line profile might be preferred. A straight-line profile helps minimize a height discrepancy between the tip and the supratip. A polly beak deformity appears unnatural and occurs when the supratip region leads the tip. A clear understanding of the nasal-tip support mechanisms is needed to predict the dynamic changes that occur during the rhinoplasty operation. Major and minor tip support mechanisms are listed below.
CONTRAINDICATIONSSection 5 of 11
Correction of a polly beak deformity is contraindicated in patients with clinically significant medical problems that may preclude safe surgery or in patients in whom psychological factors make further surgery unwise. Take care when reducing the nasal dorsum in a patient with a septal perforation. WORKUPSection 6 of 11
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TREATMENTSection 7 of 11
Medical therapyMedical treatment is possible only in the early stages of soft-tissue polly beak. Steroid injections can be administered to decrease edema and ultimately the amount of scar tissue that forms in the dead space of the supratip region. These injections can be given prophylactically in patients at increased risk of this deformity (eg, those with thick nasal skin, poor skin elasticity, large nasal reductions) or as treatment for a developing polly beak. Injections must be deep to the dermis to avoid changes in the dermis and epidermis (eg, hypopigmentation, atrophy). Triamcinolone acetonide 10 mg/mL (0.1-0.5 mL) can be injected into the area. The injection should not be administered more often than once every 3-4 weeks. Overtreatment may result in atrophy that may produce saddle-nose deformity or irregular skin changes. Diminishing returns are noted with repeated injections. Surgical therapyThe profile is aligned by balancing dorsal reduction and augmentation. The importance of preoperative nasal analysis cannot be stressed enough. This thorough assessment helps the surgeon identify problem areas, consider solutions, and mentally perform the operation before embarking on the actual procedure. For the patient with overreduced nasal bones, the nose may be balanced by using a graft placed in the region of the radix to properly reduce the cartilaginous septum. For the underresected cartilaginous dorsum, resection is recommended, with careful intraoperative assessment of the relationship to the tip. Tissue edema should be minimal to accurately judge this relationship. For the external rhinoplasty approach, redrape the skin-soft tissue envelope before evaluating the profile. In addition, account for the degree of tip settling (1-2 mm) that may occur after surgery. Fibrin glue may be used prophylactically in patients who are at high risk for a postoperative polly beak deformity. If amount of dead space between the skin and its underlying cartilaginous framework is substantial, fibrin glue can be used to promote adherence. This method helps prevent the formation of excessive scar tissue and helps improve definition of the nasal tip. As an alternative, in patients with thick skin, placement of an absorbable suture from the dermis to the deep tissues (cartilaginous dorsum of the supratip) can make the skin redrape appropriately. Tying of this suture may need to be tried several times before an appropriate position is achieved. Preoperative detailsPhotographic analysis before surgery involves evaluating the lateral view in particular. Especially focus on the area of the tip and supratip. Evaluate the relationship of the tip and supratip compared with the entire nose to accurately diagnose the problem. Physical examination complements the photographic analysis and enables accurate surgical planning. Intraoperative detailsPalpate and observe the patient's profile (lateral view) after incremental reduction or augmentation is performed. If the amount of dead space is substantial on redraping, use of fibrin glue may be useful. Postoperative detailsCareful attention to taping the nasal dorsum is critical. To lessen the degree of tissue edema (and eventual formation of scar tissue) in patients with thick skin, a material such as nonadhesive wound dressing (Telfa; Kendall, Mansfield, MA) or absorbable gelatin sponge (Gelfoam; Pfizer, New York, NY) may be placed in the area of the supratip beneath the tape and cast to provide additional pressure in this region. Follow-upRemove the cast in 1 week. Make a preliminary assessment of the outcome after the cast is removed. If edema is substantial, tape should be reapplied, and the patient should return in 1-2 weeks. Some patients may be candidates for steroid injections at this time. If a patient continues to have excessive supratip edema and scar tissue, steroid injection may be performed again at 4-6 weeks postoperatively. COMPLICATIONSSection 8 of 11
Excision of scar tissue in the supratip region may lead to thin atrophic skin and tissue loss. In general, full-thickness skin loss occurs by operating in the improper plane and by performing overly aggressive resection that transgresses the dermis. Blindness is reported as a complication of steroid injection in the region of the nasion after septorhinoplasty. The patient had immediate unilateral blindness. Proximity to the orbit might be the reason for the central retinal embolus of Depo-Medrol. Blindness resulting from injection into the supratip region is not reported. Overuse of steroid injections can result in atrophy at the site of injection. This atrophy can lead to a depression of the supratip region resulting in a saddle-nose deformity. Other skin changes, including subdermal atrophy, depigmentation, telangiectasia formation, necrosis, and ulceration, can occur. OUTCOME AND PROGNOSISSection 9 of 11
The outcome is best assessed at the 1-year follow-up visit. In patients with thick skin, a period longer than this may be needed. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Rhinoplasty, Management of the Polly Beak Deformity excerpt Article Last Updated: May 17, 2006 | ||||||||||||||||||||||||||
