You are in: eMedicine Specialties > Plastic Surgery > NOSE Rhinoplasty, OsteotomiesArticle Last Updated: Oct 7, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: John A Grossman, MD, Emeritus Chairman, Instructor, Departments of Otolaryngology and Plastic Surgery, University of Colorado Rose Medical Center John A Grossman is a member of the following medical societies: American Burn Association, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Laser Medicine and Surgery, American Society of Plastic Surgeons, Colorado Medical Society, Lipoplasty Society of North America, and Pan-Pacific Surgical Association Coauthor(s): Linda Li, MD, Consulting Staff, Department of Plastic Surgery, Hospital of the Good Samaritan Editors: Frederick J Menick, MD, Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona College of Medicine; Private Practice in Tucson, Arizona; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; George Peck, Jr, MD, Consulting Staff, Department of Plastic Surgery, St Barnabas Hospital of New Jersey; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: rhinoplasty, osteotomies, osteotomy, fractures, infracture, outfracture, breaks, bony cuts, bone excision, cutting bone, nasal surgery, nose surgery, nasal bone, nasal fracture, nose job, nasal break INTRODUCTIONSection 2 of 11
  The term osteotomy, derived from Greek, is defined in the medical dictionary as a surgical operation in which a bone is divided or a piece of bone is excised (as to correct a deformity). This article concerns the surgical technique of cutting bone in the performance of rhinoplasty (nasal surgery). ProblemMost, although not all, rhinoplasties require the use of a form of osteotomy, because most standard rhinoplasties require the movement or alteration of the osseocartilaginous vault that composes much of the nose. For information on various rhinoplasty techniques, see the following eMedicine Plastic Surgery articles:
FrequencyAmerican Society of Plastic Surgeons (ASPS) statistics for 2007 reported that more than 284,000 rhinoplasties (both cosmetic and reconstructive) were performed by its member plastic surgeons (this does not include procedures performed by otolaryngologists [ENTs], oral-maxillofacial surgeons, and others).1 For each of these surgeries, possibly 2-4 osteotomies were performed. Thus, this represents a conservative estimate of the frequency of rhinoplastic osteotomies. INDICATIONSSection 3 of 11
In general, indications for osteotomies in rhinoplasty are anatomic findings of a high nasal dorsum that requires "hump" removal, an "open roof" after the hump has been removed, and a wide nasal base. Correcting these conditions requires osteotomies. Understanding these factors requires a familiarity both with the basic anatomy of the nose and surrounding facial and cranial structures and with the goals of aesthetic (cosmetic) and functional rhinoplasty. RELEVANT ANATOMYSection 4 of 11
Simplistically, the nose is a structure consisting of a bone and cartilage framework over which is draped a skin envelope. The size, shape, quality and/or thickness, texture, and position of the various parts help determine the appearance and function of the nose. The bony portion is referred to as "the bony vault." According to Oneal, Izenberg, and Schlesinger, "[It] … consists of the paired nasal bones and the frontal ascending processes of the maxilla. The vault is generally pyramidal in shape… The most narrow part of the bony pyramid is at the intercanthal line… Laterally the nasal bones articulate with the ascending or frontal process of the maxilla…"2 Surgeons who perform rhinoplasties need to have a thorough understanding of nasal anatomy.3 CONTRAINDICATIONSSection 5 of 11
Contraindications for osteotomies lay within the contraindications for rhinoplasty. If the surgeon feels the patient is an appropriate candidate for rhinoplasty, osteotomy can be performed. Aesthetic contraindications may exist wherein the nasal vault does not require narrowing and, even after hump removal, the lateral nasal bony plates lie in close enough approximation that osteotomy is unnecessary. Such decisions are within the purview of the individual rhinoplastic surgeon. WORKUPSection 6 of 11
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TREATMENTSection 7 of 11
Surgical TherapyExcept for correction of nasal fractures or airway difficulties, rhinoplasty is an elective procedure chosen for aesthetic purposes. In these situations, ultimately, the patient is the one who decides to proceed with surgery. For additional information on aesthetic procedures, visit Medscape's Aesthetic Medicine Resource Center. Preoperative DetailsPreoperative photography of the patient is essential prior to rhinoplasty. Take photographs of the frontal view, in profile, and as a caudal-to-cranial image to demonstrate the columella and septum. Review these photographs preoperatively with the patient to discuss the areas with which the patient is dissatisfied. Digital photography in conjunction with computer programs that allow patients to see possible operative results has become popular in the past decade. Surgeons using these programs to demonstrate probable operative results need to emphasize to the patient that the depicted results are simulations and do not guarantee final postoperative results. Individual healing and scarring may alter the final results and the patient should be made aware of this possibility. In general, rhinoplasty can be performed as an outpatient procedure if the patient has adequate arrangements for transportation home as well as aftercare. The choice of anesthetic (general vs local with intravenous sedation) does not affect the patient's choice of ambulatory surgery. Unless other mitigating circumstances are present, the surgeon's preference determines the choice of anesthetic. Either the surgeon or the patient's primary care physician should perform the usual and customary preoperative workup, including laboratory work, history and physical examination, and other studies that may be appropriate given the patient's health status. Inform the patient which medications (prescription, homeopathic) to avoid (eg, aspirin and aspirin-containing medications, ibuprofen, blood-thinning medications or anticoagulants, vitamin E, fish oil capsulates, and most over-the-counter nutritional agents) and to avoid alcohol for several weeks prior to surgery. Intraoperative DetailsOsteotomy generally is the last step performed in a rhinoplasty since osteotomies can result in considerable oozing from the fractures. If performed at the end of the procedure, the surgeon then can close the incisions rapidly and place a dressing that allows pressure to be applied to help stop the bleeding. An osteotomy performed at the end of the rhinoplasty also results in less postoperative edema.
Postoperative DetailsLeave the nasal splint in place for approximately 1 week so that fracture stabilization and healing can occur. The splint and any permanent sutures may be removed after 1 week. Usually, no further dressing is necessary. The patient can expect to experience a minimal amount of bleeding from the nose, which should stop 12-24 hours postsurgery. Advise the patient to expect black and blue discolorations around the eyes, which result from the bruising caused by the osteotomies. Reassure the patient that this resolves in 1-2 weeks. Advise moderate physical activity immediately after surgery. The patient may resume strenuous physical activity within weeks of surgery; however, since the fracture lines remain delicate, and bony union requires approximately 6 weeks, certain vigorous physical activities (eg, jogging, horseback riding, skiing) should be avoided during this time. Additionally, activities that risk nasal trauma should be avoided during this time. Once bony healing has occurred, the nasal vault should be almost as resistant to fracture as it was preoperatively. Following rhinoplasty, the soft tissue of the nose develops firmness that gradually resolves over the course of about 1 year. The physical appearance is close to normal after several months and usually changes only slightly as the final tissue firmness resolves. Follow-upObserve the patient on a regular basis after surgery to ensure proper postoperative healing. Ultimately, at 1 year, the patient can expect to see his or her final operative results. Take postoperative photographs to demonstrate the results of the operations. COMPLICATIONSSection 8 of 11
Unlike soft-tissue complications from rhinoplasty, which require several months for soft-tissue swelling to resolve prior to corrections, many problems resulting from osteotomies may be addressed earlier, depending on the problem. Obvious problems with asymmetry may be corrected by refracturing the nasal bones and resplinting the fractures. Once again, caution patients to avoid activities that may cause shifting of the bones and to vigilantly leave the splint in place to allow for proper healing of the osteotomy sites. A stair-step deformity occurs when lateral osteotomies have been placed too high and a prominent ridge along the lateral aspects of the nose develops. Correction of this deformity can be performed either by fracturing the ridge and resetting it or by rasping down the bony ridge through a tunnel created from the piriform aperture. OUTCOME AND PROGNOSISSection 9 of 11
The patient can expect a fair amount of bruising and swelling in the immediate postoperative period. Until they have resolved, these symptoms may mask the final result of the osteotomies. Once the swelling and bruising have resolved, the patient is able to discern a narrower nasal base that complements the new contours of his or her nose. Unless osteotomies are unset or rebroken from physical force, natural healing of the bones occurs. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Rhinoplasty, Osteotomies excerpt Article Last Updated: Oct 7, 2008 | |||||||||||||||||||||||||||||||||||||||||||||||
