Disclosure Primary and revision rhinoplasty are challenging procedures for plastic surgeons. To obtain aesthetically pleasing results, ensure patient satisfaction, and minimize complications, the rhinoplasty surgeon must possess a thorough knowledge of nasal anatomy and ideal facial aesthetic proportions. The rhinoplasty surgeon must be familiar with all current methods to correct nasal deformities. This article addresses augmentation of the deficient nose. History of the Procedure: Rhinoplasty originated as a reconstructive procedure, which, in essence, was a form of nasal augmentation. In 500 BCE, Sushruta pioneered the Indian method of nasal reconstruction with the use of the forehead flap. In the 1800s, two German surgeons, Carl von Grafe and Johann Dieffenbach, made significant advances in rhinoplasty. Further technical advances were made in subsequent years. Dr John Roe described the endonasal approach in 1887, and Drs Joseph Safian and Gustave Aufricht made further advances in rhinoplasty techniques. Several publications continue to propose innovative ways to correct nasal deformities and improve outcomes. In addition to autologous materials, many new synthetic and allogenic materials have become available for nasal augmentation surgery. Clinical: Rhinoplasty requires a careful preoperative analysis of the patient's problem during the office visit and meticulous surgical execution in the operating room. The surgeon must elicit the expectations, concerns, and motivations of the patient seeking rhinoplasty. Establishing a good rapport with the patient can help increase the potential for satisfaction with the postoperative result. An accurate nasal history should alert the surgeon to a previous history of nasal trauma, nasal obstruction, sinus disease, and allergic disorders. A detailed history of any comorbid conditions must be elicited. A detailed history of current prescribed medications, over-the-counter medications, and herbal supplements also must be elicited. Any agents such as aspirin, anticoagulants, and herbal supplements (eg, gingko, ginger) should be discontinued at least 2 weeks prior to surgery to minimize the risk of intraoperative and postoperative bruising and bleeding. The anatomic examination should include an analysis of the external nasal deformity and internal nasal anatomy. The endonasal examination should be performed after adequate decongestion with a vasoconstrictor. Specific attention should be given to any external nasal valve collapse upon inspiration, the adequacy of the internal nasal valve, tip ptosis, septal deviation, the size of the inferior turbinates, septal perforation, and the existence of any purulence in the middle meatus. Preoperative photographs must be obtained, which should include a frontal view, lateral view in the Frankfort horizontal plane, basal view, and oblique view. Informed consent must be obtained and documented. Any questions or concerns the patient has should be addressed prior to the surgical procedure.
Functional and/or aesthetic concerns may prompt a patient to seek rhinoplasty surgery. The nose functions as an airway conduit. It filters and humidifies air as it passes through the nasal cavity. Any obstruction to the airflow may be bothersome to patients. To effectively treat the problem, anatomical and/or medical causes of nasal obstruction must be sought. Several publications describe algorithms that can help the surgeon with the differential diagnosis. Canady proposed an algorithm that can help determine whether a patient has an allergic problem, a mucosal problem, or other anatomical problem that is causing nasal obstruction. Nasal obstruction secondary to anatomic deformities or variations from the ideal nasal aesthetics can be improved with surgical intervention. Examples include internal nasal valve and/or external nasal valve collapse upon inspiration. The internal nasal valve is formed by the septum medially and the upper lateral cartilages superiorly. The ideal angle for adequate airflow has been reported to be 10-15°. Inadequate airflow can occur when this angle is more acute. In addition, encroachment of the inferior turbinate laterally at the internal nasal valve can further worsen the obstruction. Internal nasal valve collapse is observed in some patients who have previously undergone a nasal dorsal reduction during a rhinoplasty. Overresection of the nasal dorsum and the upper lateral cartilages can lead to loss of structural support at the internal nasal valve, which can result in obstruction. Correction of this condition usually requires reestablishing the normal angle with the use of spreader grafts between the septum and the upper lateral cartilages. Patients also may require external nasal valve augmentation with batten grafts, rim grafts, or other structural support for a patent airway. The inferior turbinates may need to be reduced or partially excised. Tip ptosis can also lead to nasal obstruction. Tip ptosis can result from aging, trauma, or previous surgical intervention that caused a loss of the crucial tip-supporting mechanisms. Augmentation of the nasal tip with grafts and restoration of the tip supporting mechanisms may be required to alleviate functional nasal obstruction. Another indication for augmentation of the nose is a deficient nasal dorsum. Nasal dorsal deficiency can result from overresection of the nasal dorsum during a prior rhinoplasty or can be present in patients with Wegener granulomatosis. Such factors can cause a saddle-nose deformity due to the loss of underlying septal support. These patients require nasal dorsal augmentation. Augmentation materials Several different materials can be used to augment the nose. Available augmentation materials can be classified as autologous grafts and nonautologous graft materials. The main nonautologous materials include Medpor, silicone, silastic, Gore-Tex, and the acellular dermis product marketed as AlloDerm. Opinions regarding the indications for and outcomes with using these materials vary. Godin et al reviewed 137 patients who underwent nasal augmentation with Gore-Tex patches. The infection rate was low at 2.2%, and none of the patients required further augmentation. The authors were pleased with the results and listed technical points they felt were important for success. Taylor and Owsley also related their satisfaction with Gore-Tex for nasal augmentation. In their study of 106 patients, they found no complications related to the graft. Studies on other implant materials have revealed mixed results. However, Rohrich and Muzaffar, in addition to many other rhinoplasty surgeons, prefer autologous materials over nonautologous materials for nasal augmentation. Autologous materials consist of bone, cartilage, or both harvested from the nasal septum, ear, rib, and calvarium. Many prominent surgeons believe that autologous materials are readily available and that the morbidity associated with harvesting the autologous grafts is low. They also believe the aesthetic and long-term functional outcomes are superior and the complication rates are low. Therefore, they advocate the use of autologous grafts over nonautologous materials. Bone is usually needed only in patients with very deficient dorsi with saddle-nose deformities. Autologous tissues may also be required in patients with severe nasal defects in whom near-total reconstruction is planned. Stuzin and Kawamoto reported their use of cranial bone grafts to correct saddle-nose deformities. These grafts require careful placement and rigid fixation. The cartilage grafts can be used as struts or as morselized/crushed grafts wrapped in fascia, Surgicel, or other components. In some cases, a combination of autologous and nonautologous materials may be necessary. One concern with bone grafts is the potential for resorption. Powell and Riley reviewed 850 calvarial bone grafts to the nose in 170 patients and found resorption rates of as high as 30%. Given this concern and the increased morbidity of harvesting bone grafts, most surgeons prefer using cartilaginous grafts. Septal cartilage should be harvested with caution. At least a 10-mm dorsal and caudal strut is very important for nasal structural support. In revision rhinoplasty cases, septal cartilage may not be available. In such cases, ear cartilage, rib cartilage, or both can be harvested. Some inherent disadvantages with the use of auricular cartilage are the inherent curves in ear cartilage and the fragility of the cartilage compared with septal or rib cartilage. However, ear cartilage is ideally suited for alar rim and nasal tip reconstruction. The amount of ear cartilage available is usually inadequate for dorsal augmentation. Ear cartilage can be harvested via an anterior or posterior approach. The resultant morbidity is minimal in either approach. When more structural support or rigidity is needed for augmentation, rib cartilage is a great alternative. The ninth floating rib is an ideal location to harvest the graft. This location provides the surgeon with a long, straight piece of structurally strong cartilage. Adherence to the Gibson principles of balanced cross-sectional harvesting leads to an ideally shaped graft that holds its final shape without distortion or warping. This involves amputation of an equal amount of cartilage from both sides to minimize warping of the graft. Meticulous surgical technique is required to prevent inadvertent entry into the thoracic cavity. With adherence to sound surgical principles, the rate of donor site complications is usually very low.
Relevant Anatomy: The nose is composed of skin, subcutaneous tissue, nasal mucosa, cartilage, and bone. The upper third of the nose is composed of the nasal bones, the middle third is composed of the nasal septum and the upper lateral cartilages, and the lower third encompasses the lower lateral cartilages and the caudal aspect of the cartilaginous septum. The midline septal cartilage provides underlying support to the lower two thirds of the nose. While this is the basic anatomic framework, variations and asymmetry are present in many individuals. The nasal bones vary in thickness and width from the nasofrontal suture line cephalically to the end of the nasal bones caudally. They are thick and widest at the nasofrontal suture, narrow at the nasofrontal angle before they widen, and become thinner approximately 9-12 mm below the nasofrontal angle. These anatomic variations in thickness and width are important to remember when osteotomies are planned. The thickness of the soft tissue and skin of the nose also varies at different anatomic points. The skin and soft tissue covering the nasal skeleton is thickest in the supratip region, while it is thinnest at the bony cartilaginous junction of the nasal dorsum. These variations in skin and soft tissue thickness affect the final nasal contour and profile after nasal augmentation. Contraindications: Augmentation rhinoplasty has relatively few contraindications. Any medical condition that inhibits patient safety during the procedure is a contraindication. Patients should not be taking any anticoagulants (eg, enoxaparin [Lovenox], warfarin [Coumadin], heparin [Hep-Lock]), aspirin, or nonsteroidal anti-inflammatory drugs before the surgical procedure. Any herbal supplements such as ginger or gingko should also be avoided. Allergies to any type of nonautologous material must be identified prior to the procedure. Patients with inappropriate motivations for seeking rhinoplasty must be carefully screened. |
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Intraoperative details: Surgical techniques may vary based on the surgeon's preference or experience. Numerous surgical technical descriptions are available in the rhinoplasty literature. Ortiz Monasterio and Michelena review several techniques for nasal dorsal augmentation. Decongestion of the nasal mucosa with oxymetazoline, phenylephrine, or cocaine-soaked pledgets allows adequate endonasal visualization. Injection of the nasal soft tissues with lidocaine and epinephrine allows adequate vasoconstriction and decreases intraoperative bleeding. Augmentation can be performed via an endonasal or an open rhinoplasty approach. The approach used depends on the complexity of the augmentation and the surgeon's preference. The endonasal approach requires an intercartilaginous, transcartilaginous, or intracartilaginous incision. In addition, a hemitransfixion or complete transfixion incision may be needed. An open approach involves elevation of the skin and soft tissue envelope via a transcolumellar incision that is carried along the medial crura and the caudal aspect of the lower lateral cartilages. The entire cartilaginous skeleton of the lower and upper lateral cartilages should be exposed. Dissection should proceed in a submuscular aponeurotic plane. Dissection superficial to this plane results in compromise of the vascular supply to the soft tissues and makes the dissection very difficult. At the bony cartilaginous junction, the periosteum over the nasal bones is elevated and the dissection is carried in this plane up to the nasofrontal angle. The entire nasal skeleton should be adequately visualized. If a septoplasty is required for septal cartilage harvest or for correction of a septal deviation, the mucoperichondrium and the mucoperiosteum over the nasal septum is elevated from above via the open technique or through a hemitransfixion or complete transfixion incision via an endonasal approach. Once the anatomy and the defects are adequately visualized, any further cartilage or bone harvest is performed. This may involve harvesting ear or rib cartilage. The 2 most frequent areas for augmentation are the nasal tip and the nasal dorsum. Grafts are fashioned and sculpted to the desired size and shape and are sutured in the desired location. The graft is secured in place with carefully placed, multiple 5-0 clear nylon or polydioxanone sutures. Corrections are performed until the desired outcome is achieved. After augmentation is complete, incisions are closed endonasally with absorbable sutures. In the open technique, the skin and soft tissue envelope are carefully redraped over the nasal skeleton and sutured in place with 6-0 nylon, Prolene, or other absorbable sutures. Septal splints may be needed if septal cartilage was harvested. Any additional nasal packing may be performed based on the surgeon's preference. An external nasal splint may be needed if osteotomies were performed. Postoperative details: Patients are educated on standard postoperative instructions. Patients are instructed to rest and sleep with the head of the bed elevated at 30-40°. Any lifting, straining, or vigorous physical activity should be strictly prohibited. Most preoperative medication can be resumed after consultation with the patient's primary care physician. Nasal mucosa should be kept moist with the use of saline sprays. Any sutures and splints should be removed in 5-7 days. If splints and packings are used, appropriate postoperative prophylactic antibiotics should be administered. Patients should be educated on the normal healing process and the time required for the edema to subside. Follow-up care: Postoperative follow-up visits are generally scheduled for 1 week, 1 month, 3 months, and 1 year after surgery. Any revisions, if necessary, should not be performed before 12 months after the initial operation. Rhinoplasty patients often require reassurance and patience. Good and open communication with the patient is mandatory during the recovery period.
As is true in other surgical procedures, occasional postoperative complications should be expected in rhinoplasty. Fortunately, most complications are minor. In general, approximately 5-15% of patients require a revision rhinoplasty. Serious complications occur in less than 3% of patients and consist of postoperative bleeding, infection, implant or graft extrusion, recurrence of the problem, or anesthesia-related problems. Endo et al reviewed 1200 cases of augmentation rhinoplasty using ear cartilage grafts and found that 4% of patients developed complications. Graft malposition was the most common problem. Other problems that can occur include graft resorption, graft extrusion, malposition of the graft, or warping of the graft. These problems may take several years to become evident. Sheen reviewed his extensive experience with nasal tip grafts. In this 1993 series he noted that graft malposition was the most common complication. If revisions are necessary, several options may be available to the rhinoplasty surgeon. Crushed cartilage, AlloDerm, and other nonautologous grafts can be used in revision rhinoplasty. Although occasional complications cannot be avoided, they can certainly be minimized with appropriate patient selection, careful preoperative planning, meticulous intraoperative surgical technique, and good postoperative follow-up.
Rhinoplasty surgery has become more predictable over the years. As the understanding of the nasal anatomy and nasal/facial aesthetics has improved and the availability of augmentation materials has increased, the surgical outcomes have become more consistent and predictable. Rhinoplasty surgeons should thoroughly understand the anatomy, have an appreciation of facial and nasal aesthetics, accurately define the surgical problem, and adhere to meticulous surgical technique. Doing so ensures consistent results and minimizes complications.
As new nonautologous materials become available, rhinoplasty surgeons will have more tools to augment and correct nasal deformities.
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