Chapter 75. Rhinoplasty

History

The term rhinoplasty is derived from the Greek word “rhinos” which means nose and “plastikos” which means “to shape.” Rhinoplasty is surgery that changes the appearance of the nose. More recently, the term “functional rhinoplasty” has been used to describe surgery that, in addition to changing appearance, also improves the function. Nasal reconstruction was first described in Ancient India by Sushruta in his text Sushruta Samhita circa 500 BC. Sushruta, considered to be the father of plastic surgery, used a variety of techniques to reconstruct nasal amputations, a common form of capital punishment at the time. These included pedicled, rotation flaps of the cheek and forehead. In the late 1500s, Professor Gaspare Tagliacozzi published a surgical textbook in Bologna showing nasal reconstruction using a flap from the upper arm. In the mid-1800s, Johann Freiderich Dieffenbach further refined the plastic surgical procedures of his time in his textbook titled Operative Surgery. He described techniques to reduce the size of the nose, such as excising a portion of abnormally enlarged nasal ala and making cruciate excisions of skin and cartilage. Aesthetic rhinoplasty though an intranasal approach was first described by American otolaryngologist John Orlando Roe in 1887 in his landmark article “The deformity termed ‘pug nose” and its correction by a simple operation.” In the late 1800s, Jacques Joseph arose as one of the most important figures in facial plastic surgery and was the pioneer of modern rhinoplasty. Joseph gave numerous lectures and practical courses on rhinoplasty that were attended by surgeons like Gustave Aufricht, Joseph Safian, Jacques Maliniac, John Maurice Converse, and Samuel Fomon. Fomon then began teaching a rhinoplasty course based upon Joseph's techniques. Two notable otolaryngologists who attended the courses were Maurice Cottle and Irving Goldman. As these surgeons trained other surgeons and surgical techniques became more refined, modern rhinoplasty was developed.

Essentials of Diagnosis

• The nose is made up of nine subunits—nasal dorsum, tip, columella, the paired nasal sidewalls, ala/sills, and soft triangles
• The three major tip support mechanisms are the strength and integrity of the lower lateral cartilages, and their attachments to the septum and to the upper lateral cartilages
• The internal and external nasal valves account for much of the nasal resistance to airflow and must be accounted for when performing rhinoplasty.

Surface Anatomy

The external surface of the nose is divided into nine subunits. They consist of the nasal dorsum, tip, columella, the paired nasal sidewalls, ala/sills, and soft triangles. The subunit principle described by Burget and Menick is based upon the notion that the human eye detects the shadowed valleys and lighted ridges of the nasal surface. This principle applies equally in nasal cosmetic surgery and in nasal reconstruction. In cancer or trauma, if more than 50% of a nasal subunit is lost, the remainder of the subunit should be removed. Thus, the whole subunit is replaced with scars designed to lie in the shadowed borders between subunits.

There are numerous facial and nasal anatomic landmarks that must be understood prior to performing an appropriate analysis (Figure 75–1). The ideal facial height divides the face into equal thirds between the trichion, glabella, subnasale, and menton. The ideal facial width divides the face into equal fifths. Thus, the width of one eye should be one fifth of the total facial width and equal to the intercanthal distance and nasal base width. Deviations from these ideals due to racial and ethnic differences are common.

Skin-Soft Tissue Envelope

The nose is composed of a bony-cartilaginous framework that is enveloped by a skin-soft tissue covering. This covering is thick at the nasion and tip and thin over the rhinion. This is important when reducing the bony and cartilaginous nasal dorsum as the varied skin thickness will influence the ultimate dorsal contour. Deep to the dermis, there are five soft-tissue components: a superficial fatty panniculus, a fibromuscular layer, a deep fatty layer, a longitudinal fibrous sheet, and an interdomal ligament. The fibromuscular layer consists of the nasal mimetic muscles that are encased and interconnected by the nasal superficial musculoaponeurotic system (SMAS). This nasal SMAS is continuous with the SMAS of the face. The proper plane when elevating nasal tissue whether for a rhinoplasty or nasal reconstruction is in the sub-SMAS plane.

The Bony/Cartilaginous Skeleton

The upper third of the nose consists of the paired nasal bones. These bones articulate superiorly with the frontal bone at the nasofrontal suture, superolaterally with the lacrimal bone, inferolaterally with the frontal process of the maxilla, and inferoposteriorly with the perpendicular plate of the ethmoid bone. The nasion refers to the bony nasofrontal suture, whereas the sellion denotes the soft tissue overlying that area. The radix is the root of the nose that encompasses both the nasion and sellion. The glabella is the prominence of the frontal bone between the eyebrows and is above the radix.

The cartilaginous septum makes up the middle third of the nasal dorsum. It is quadrangular in shape and articulates posteriorly with the bony septum (perpendicular plate of the ethmoid bone and vomer) and inferiorly with the maxillary crest. The caudal aspect of the cartilaginous septum has a defined anterior septal angle and posterior septal angle that play a significant role in the position of the nasal tip.

The upper cartilaginous vault is composed of the paired upper lateral cartilages (ULCs). These structures are triangular or trapezoidal in shape and fuse in the midline to the cartilaginous dorsum. The ULCs are also supported cephalically by their attachments to the nasal bones. The region where the ULCs attach to the under-surface of the nasal bones is called the keystone area. The cephalic aspect of the ULCs may overlap the caudal part of the nasal bones by up to 11 mm. It is imperative to maintain this relationship to prevent collapse of the ULCs and subsequent nasal obstruction. Caudally, the ULCs articulate with the lower lateral cartilages (LLCs) at the scroll.

The lower cartilaginous vault consists mainly of the paired LLCs or alar cartilages. The LLCs, which are extremely variable among individuals, determine the shape and configuration of the nasal tip. The refined tip is described by the double-break appearance, which consists of a supratip and infratip break. The supratip is defined by the junction of the nasal dorsum and the nasal tip, and the infratip is defined by the junction of the tip and columella.

The LLCs are C-shaped and may be divided into three parts: the medial crus, intermediate or middle crus, and lateral crus (Figure 75–2). The medial crura are the narrowest segment of the LLC. Each consists of a footplate segment that flares posterolaterally and an anterior segment that defines the contour of the columella. The medial crura are attached to the caudal septum by fibrous tissue and are separated from each other by loose connective tissue.

The intermediate crura join the medial crura to the lateral crura. The intermediate crura flare posterolaterally away from each other at the angle of divergence. The angle of divergence contributes to the infratip lobule and normally measures approximately 50–60°. Angles greater than 60° typically lead to a wide or boxy tip. The dome is a point where the intermediate crus joins the lateral crus and is the highest and most anterior point of the tip. The domes are joined medially by the interdomal ligaments. The domes correspond topographically to the tip-defining points and as such, surgical maneuvers to modify the domes are used to refine the nasal tip.

The lateral crura are typically convex in shape and extend posteriorly from the intermediate crura. The lateral crura initially parallel the alar rim, but then turn posteriorly, superiorly, and laterally toward the pyriform aperture. There is a variety of anatomic relations between the cephalic margin of the lateral crura and the caudal margin of the ULCs at the scroll region. Variations in width, shape, and strength of the lateral crura influence both the appearance and strength of the nasal tip.

Tip Support Mechanisms

Many surgeons would argue that the key to rhinoplasty is controlling the nasal tip. It is imperative to understand tip support and dynamics in order to achieve predictable results. Two related models have developed to help explain the complexities of the nasal tip cartilages: the tripod theory and the tip support mechanisms.

In the tripod concept, the anatomy of the LLCs is compared to that of a tripod where the conjoined medial crura formed one leg and each of the lateral crura represented the remaining two legs (Figure 75–3). Hence, in theory, changes in the length of the limbs of the tripod lead to predictable changes in the nasal tip position. Decreasing the lengths of all three limbs equally results in tip deprojection whereas increasing the lengths would increase projection. Shortening the length of the medial crura and/or lengthening the lateral crura would result in caudal tip rotation, whereas the opposite maneuvers would lead to cephalic tip rotation.

The nasal tip classically has nine support mechanisms: three major and six minor. The major tip support mechanisms are: (1) the size, shape, and resiliency of the LLC; (2) the attachment of the LLCs to the caudal septum; (3) the attachment of the LLCs to the ULCs at the scroll region. The minor tip support mechanisms are: (1) the interdomal ligament; (2) the cartilaginous dorsal septum; (3) the sesamoid complex; (4) the attachment of the LLC to the overlying SMAS and skin; (5) the nasal spine; (6) the membraneous septum. When performing nasal surgery, tip support mechanisms need to be respected, and if weakened must be reconstituted to ensure a good functional and aesthetic outcome.

Nasal Valves

The nose is responsible for about two-third of the body's total resistance to airflow during breathing. There are two main valves in the anterior aspect of the nose that account for the majority of resistance: the internal nasal valve (INV) and the external nasal valve (ENV).

The INV is the narrowest segment of the nasal cavity and is the greatest resistance to nasal airflow. The INV is bordered by the septum, the head of the interior turbinate, the caudal edge of the ULC, and the pyriform aperture. The attachment of the ULC to the septum normally occurs at an angle of 10–15° in Caucasians. A connection at a more acute angle may lead to nasal obstruction. INV static narrowing or dynamic collapse and subsequent nasal obstruction may be caused by previous surgery, trauma, septal deviation, inferior turbinate hypertrophy, scarring, synechiae, or congenital malformations. The ENV is formed by the nasal floor/sill, the columella, and the caudal border of the LLC. ENV static narrowing or dynamic collapse may be caused by prior surgery, weak LLCs, a widened columella, thick skin-soft tissue envelope, deviated caudal septum, or nasal stenosis due to trauma or burns.

Essentials of Diagnosis

• There are numerous ideal aesthetic proportions that are used in the preoperative evaluation
• The standard views for preoperative rhinoplasty include: frontal, three-quarters, lateral, and base.

Nasal Analysis

Although beauty is truly in the eye of the beholder, various formulas and calculations have been derived to determine the ideal aesthetic nasal proportions. Preoperative analysis of the nose and how it relates to the rest of the facial units is the cornerstone of rhinoplasty. Table 75–1 shows the parameters that may be evaluated and analyzed in the frontal, lateral, and basal views.

In the frontal view, the brow-tip esthetic line is a gently curved line from the medial eyebrow along the nasal dorsum to the ipsilateral light reflex. In a refined, symmetric nose, the two lines should form an hourglass figure. Also in the frontal view, the columella should be slightly inferior to the alar rims, the contour of which resembles a “gull in flight” silhouette. The frontal view is the most difficult view to achieve perfect symmetry. As such it is the most useful view in evaluating preoperative asymmetries and postoperative results. A useful supplement to the frontal view is the frontal smiling view. With this view, dynamic changes with smiling will often highlight asymmetries that are hidden in the unsmiling, the standard frontal view.

The lateral view is taken keeping in mind the Frankfort horizontal, an imaginary line from the top of tragus to the malar eminence. This line should be horizontal for the lateral view to best be used in interpreting the various aesthetic angles. In the lateral view, there are four aesthetic angles that are determined based upon the geometry of the nasal dorsum: nasofrontal angle (Figure 75–4), nasofacial angle, nasolabial angle (Figure 75–4), and nasomental angle. The nasofrontal angle is defined by the intersection of a line connecting the glabella and nasion and a line tangent to the nasal dorsum. The ideal measurement is 115° to 130°.

The nasolabial angle is determined by the intersection of a line tangent to the columella and a line from the subnasale to the upper vermilion border. The ideal measurement is 90° to 95° in men and 95° to 110° in women. A caudally rotated tip is often associated with a more acute angle and a cephalically rotated tip, a more obtuse angle. However, absolute tip rotation is determined by the angle of rotation of the dome off the Frankfort horizontal and so is not equivalent to the nasolabial angle.

The nasofacial angle is determined by the intersection of a line tangent to the nasal dorsum with a line from the glabella to the soft tissue pogonion. The ideal measurement is 36° to 40°. The nasomental angle is defined by the intersection of the line from the tip-defining point to the soft tissue pogonion and a line tangent to the nasal dorsum. The ideal measurement is 120° to 132°.

Nasal projection is best quantified on the lateral view. Numerous methods have been described to calculate nasal projection, but the three most commonly used are Goode's method, Crumley's method, and Simon's method. Goode's method states that a line from the alar-facial groove to the nasal tip equals 0.55–0.6 of the length of the nasal dorsum. Crumley related the nasal profile to a right triangle with vertices at the nasion, alar crease, and tip-defining point. The sides of the triangle should have a 3:4:5 ratios with a resultant nasofacial angle of 36°. Simon's method related nasal tip projection to the length of the upper lip. He determined that the distance from the subnasale to the upper vermilion border should equal the distance from the subnasale to the tip-defining point.

On the base view, the surgeon may assess the width of the ala that ideally equals the intercanthal distance. Alar flare, or the widest point of the mid-ala, can also be assessed. The relationship between the columella and the infratip lobule, ideally 2:1, is also easily seen. This is also the best view to assess any deflection of the caudal septum and the effect it has on the columella and nasal tip.

The oblique (or ¾) views can enhance the overall evaluation by assessing the relationships between the dorsum, tip, and sidewalls and adding to the three-dimensional insight of the nose. On this view, if the dorsum is deviated from the midline, it will appear higher when photographed from the opposite side. In other words, a dorsum that is deviated to the right will appear higher on the left oblique view and lower on the right oblique view.

Initial Consultation

It is imperative to take a thorough history with all patients who are operative candidates. In addition to the standard medical/surgical history, questions regarding nasal obstruction, allergic rhinitis, and chronic sinusitis should be included. If the patient has signs and symptoms of chronic sinusitis warranting sinus surgery, this may be done in conjunction with rhinoplasty. In addition to the standard medical history, cosmetic patients may be asked about their motivations, goals, and expectations for surgery. Understanding patient's motivations will give the surgeon a better chance of insuring a successful outcome. In particular, patients who are overly preoccupied with trivial aspects of their appearance and who overstate what the surgery will do for their lives might best be screened for body dysmorphic disorder by a psychiatric professional.

Physical examination begins with the skin quality and texture. Although thick skin makes it more difficult to achieve tip definition, it does help to conceal cartilaginous tip irregularities. Furthermore, patients with thick skin tend to have more postoperative edema. A great deal of information regarding nasal anatomy can be gained via palpation. Nasal bones should be palpated both for irregularities and to assess bony length in relation to ULC length. Special care should be taken of patients with short nasal bones and long ULCs as they are predisposed to nasal valve collapse. The LLCs are palpated to evaluate size, shape, and strength. The tip recoil test is done by pressing the fingertip against the nasal tip and releasing it to determine the degree of resilience. If the tip resists retrodisplacement or springs back to its prior position, then the LLCs are probably able to retain satisfactory support following surgical manipulation. The caudal septum should also be palpated to assess deflection as well as to confirm the presence of septal cartilage in any secondary rhinoplasty.

In addition to examining the nasal anatomy in a static form, it is also imperative to perform a dynamic nasal examination. Classically, the Cottle maneuver is used to assess nasal valve incompetence. The standard Cottle maneuver is performed by distracting the cheek laterally; the modified Cottle maneuver supports the external and internal nasal valves using a cerumen curette during inspiration. This may be quantified by having the patient rate his nasal patency on each side independently on a ten-point scale at baseline, with support of the internal nasal valve, and with support of the external nasal valve.

Intranasal examination is performed using a speculum, headlight, and endoscope if indicated. It is necessary to evaluate for septal deviation or perforation, inferior turbinate hypertrophy, synechiae, and nasal valve scarring or stenosis. These abnormalities should be identified preoperatively and addressed in combination with rhinoplasty.

Photographs are taken of all patients as a guide to preoperative planning, as a teaching tool, and for medicolegal purposes. Pictures are typically taken in front of a blue background to provide a nice contrast to the human face. Standard views for preoperative rhinoplasty include: frontal, three-quarters, lateral, and base. Frontal and lateral smiling views help assess dynamic tip movement and asymmetries. Overhead views of the dorsum and tip may highlight dorsal deviations. Numerous computer programs are available that can morph these images to show patients how a realistic surgical result may appear.

Essentials of Diagnosis

• The incisions used in rhinoplasty include: intercartilaginous, intracartilaginous, marginal, and transcolumellar
• Rhinoplasty may be performed through an open, or external, approach or through a closed, or endonasal, approach
• Rhinoplasty surgery addresses the bony and cartilaginous dorsum, nasal valves, tip, and nasal base
• Cartilage grafts may be taken from the septum, ear, or rib.

Intraoperative Considerations

Rhinoplasty surgery may be performed either under sedation or general anesthesia. Once the patient is asleep, cocaine soaked pledgets are placed intranasally under the nasal bones, against the septum, and in the vestibule. A mixture of 1% lidocaine with epinephrine 1:100,000 on a 1.5-inch 27-gauge needle is injected regionally for infraorbital, supratrochlear, and pyriform aperture blocks. The septum, columella, tip, and nasal sidewalls are then injected. Injection is given paradorsally to prevent any distortion of the midline dorsum. During the surgery, the medial and lateral surfaces of the frontal processes of the maxillae are injected prior to performing osteotomies.

Incisions

There are a variety of incisions that vary with the approach that allow the surgeon to access the septum, LLC, ULC, and nasal bones.

Incisions with the endonasal (closed) approaches: to expose the cartilaginous and bony septum, a hemitransfixion incision, (placed at the caudal septum) or a Killian incision (placed more posteriorly) may be used. An intercartilaginous incision is placed between the LLC and ULC (Figure 75–5). The incision begins posterior-laterally between the two cartilages and is carried anteromedially over the anterior septal angle. When exposure of the nasal tip is warranted, the incision is connected with a transfixion incision. A transcartilaginous or intracartilaginous incision is placed more caudally than the intercartilaginous incision and splits the cartilage of the lateral crus longitudinally. A marginal incision follows the caudal margin of the LLC (Figure 75–5). The marginal incision differs from the rim incision which is along the skin of the alar rim. Rim incisions are rarely performed since they may cause visible scars and alar retraction.

Incisions with the external (open) approach: the transcolumellar incision is through the skin of the midcolumella (Figure 75–5). Typically, the incision is made at the narrowest part of the columella, since the skin is thinnest and closely approximated to the underlying medical crural cartilage at this point. An inverted-V, stair-step, or other broken line incision is used to minimize scar visibility and contracture. The incision continues as a marginal incision intranasally. Some surgeons make a separate hemitransfixion incision to access the septum, while others will access it either by dissecting between the medial crura through the membranous columella, or by separating the ULCs from the dorsal septum and accessing it from above.

Approaches

There are two standard approaches to performing rhinoplasty surgery—endonasal/closed or external/open. Each has its own advantages and disadvantages. The approach that allows the surgeon to achieve the best outcome in his or her hands is the one that is best employed.

Endonasal rhinoplasty may be divided into the nondelivery and delivery approaches. There are two nondelivery approaches: the cartilage splitting and the retrograde. The cartilage splitting approach utilizes an intracartilaginous incision while the retrograde approach utilizes an intercartilaginous incision. Either of these approaches may be used when minimal tip refinement is needed since there is limited exposure of the LLC. The delivery approach employs an intercartilaginous and marginal incision and allows delivery of the LLC as a bilateral pedicled chondrocutaneous flap. This approach yields good visualization of the entire LLC without producing an external scar. Grafts are typically placed in perfect pockets rather than being sewn into position. However, this approach does compromise tip support since it disrupts the attachment of the LLC to the ULC and between the LLC and the septum (when a full transfixion is made).

External or open rhinoplasty approach affords the surgeon maximal exposure of the nasal skeleton and allows for accurate placement and suturing of grafts. Additionally, the nasal cartilages are operated upon in their natural anatomic position, allowing greater accuracy in establishing relationships between the various parts of the nose. The exposure of the underlying nasal anatomy is invaluable in resident education. The disadvantages of open rhinoplasty are that it takes longer to perform and may result in more postoperative edema. The external columellar scar, much maligned in the past, is not visible when executed and closed properly.

Bony Dorsum

Most surgeons prefer to adjust the nasal dorsum first and then make the necessary tip refinements; however, the opposite may also be done. There are four maneuvers typically performed on the nasal dorsum: reduction, augmentation, narrowing, and straightening.

Over-projection of the nasal dorsum may be due to overgrowth of the cartilaginous dorsal septum and/or the nasal bones. The cartilaginous dorsum is usually addressed first and is resected incrementally using either a #11 or #15 scalpel, or scissors. It is imperative that the surgeon spare the ULC while resecting the cartilaginous dorsum to prevent middle vault collapse. Once the cartilaginous dorsum has been reduced to the desired level, the nasal bones are then reduced to the appropriate height. Reduction of a bony hump may be performed using an osteotome and/or rasps.

Some patients have an insufficient nasal dorsal height and require augmentation. Both autologous and nonautologous graft materials have been developed for this purpose. Nonautologous materials include high-density porous polyethylene (Medpore, Porex Surgical Inc., Irvine, CA, USA), solid silicone rubber (Silastic), expanded-polytetrafluoroethylene (Gore-Tex, W. L. Gore and Associates, Flagstaff, Arizona), and acellular human dermis (Alloderm, LifeCell Corp., Branchburg, NJ). These materials may produce good results but surgeons must be cautious of the potential for infection and extrusion.

The septum is typically the first choice for cartilage graft harvest. Harvesting septal cartilage has little morbidity, requires no external incisions, and can yield a sufficient amount of cartilage. It is important that when removing portions of the quadrangular cartilage, at least 1cm of cartilage is left caudally and dorsally (“L strut”) to prevent a saddle nose deformity. Furthermore, careful elevation of the mucoperichondrial flaps but be performed to prevent a perforation. Mattress sutures are usually placed after harvesting septal cartilage to appose the two flaps and decrease the risk of a septal hematoma.

In patients who do not have enough septal cartilage for grafting purposes, ear cartilage is usually the next donor site area. The conchal cartilage is removed, preferably from a postauricular approach, leaving the resultant auricular framework intact. Auricular cartilage possesses a natural curve and is softer and weaker than septal cartilage. Thus, it often needs to be folded on itself to produce a straight graft that may also provide support. Dissolvable mattress sutures through and through the ear are placed to prevent an auricular hematoma.

Rib cartilage is typically used either when an abundance of cartilage is required or significant support must be restored. Rib cartilage may be autologous or homologous (irradiated cadaveric costal cartilage). Most authors prefer autologous cartilage, although there is good support for using homologous cartilage in certain cases in the literature. The incision is placed in the inframammary crease and usually the sixth rib is harvested. When harvesting rib cartilage, extreme care must be taken to avoid violating the pleura, which could result in a pneumothorax. Many surgeons advocate getting a postoperative chest X-ray in all patients undergoing rib harvest. Rib cartilage is extremely firm and rigid and is more difficult to carve than septal or auricular cartilage. In addition, rib cartilage is prone to warping over time. All perichondrium should be removed in an effort to reduce this problem.

Any cartilaginous graft used for dorsal augmentation must be precisely contoured by adjusting the shape and thickness, and beveling the edges, of the graft. Over the time, especially in thin-skinned patients, cartilage grafts may become visible under the skin. To combat this problem, some surgeons place temporalis fascia or other soft tissue over the grafts to provide further camouflage. Newer techniques have been developed such as finely dicing the cartilage and wrapping it with temporalis fascia to further minimize the risk of a visible graft.

Osteotomies

Many patients present with a widened nasal pyramid that requires narrowing to obtain a more refined appearance. Narrowing the upper third of the nose is done by making osteotomies along the lateral and medial aspects of the nasal bones. Osteotomes come in various sizes and may be straight or curved. Some osteotomes are guarded in that they have blunted leading edges to assist the surgeon in palpating the location along the nose, and theoretically automatically raise a periosteal tunnel, while others do not. Prior to performing osteotomies, some surgeons elevate the periosteum off the lateral nasal bones to create a tunnel for the osteotome. Some surgeons perform curvilinear osteotomies intranasally by which the osteotome is introduced through an incision just anterior and superior to the head of the inferior turbinate. Other surgeons perform percutaneous osteotomies where a small osteotome (usually 2 mm) is placed through a stab incision at the midportion of the nasomaxillary junction. In this technique, the osteotome is used to perforate or “postage-stamp” the bone in the proposed path of the osteotomy to allow a precise fracture. Some surgeons have adopted a method of doing perforating osteotomies via an intranasal approach.

The most widely accepted path for lateral osteotomies is high (anterior), low (posterior), high (anterior) (Figure 75–6). The osteotome is placed slightly above the pyriform aperture to leave a small triangle of bone intact to maintain the attachments of the lateral alar suspensory ligaments. The osteotome travels posterolaterally, cutting through the pyriform aperture bone until the face of the maxilla. The osteotome is the directed superiorly along the junction of the frontal process of the maxilla and the face of the maxilla. At the nasal bones, the osteotome is then guided anteromedially. In certain patients, a lateral osteotomy alone is sufficient to produce a clean back-fracture of the nasal bones with resultant narrowing. Other patients may require medial osteotomies for a more controlled back-fracture. These are performed by placing the osteotome at the paramedian aspect of the caudal nasal bone, adjacent to the superior septum. The osteotome is then guided in a supero-lateral direction toward the medial eyebrow so as to connect to the superior portion of the lateral osteotomy. Intermediate osteotomies are placed in between the medial and lateral osteotomies and are typically done when one nasal bone is significantly longer or more convex than the other to make them more symmetric. A transverse root osteotomy is a percutaneous horizontal osteotomy through the root of the nasal bone at the nasion using a 2 or 3 mm osteotome. This is employed when the nasal bone deviation occurs superiorly at the nasal root.

Middle Third and Nasal Valves

The middle third of the nose is composed of the ULC and dorsal septum. As aforementioned, the ULC is a major component of the INV and weakness of the cartilage may lead to collapse and nasal obstruction. Numerous techniques have been described to treat nasal valve collapse depending upon the etiology. Two of the more popular techniques include spreader grafts and flaring sutures. Sheen described the use of spreader grafts, placed between the septum and ULC to lateralize the ULC and increase the cross-sectional area of the INV. Park described the use of flaring sutures, horizontal mattress sutures placed through the caudal/posterior aspects of both ULCs and across the nasal septum. By tightening this suture over the nasal dorsum, the ULCs flare laterally and increase the INV angle. The conchal cartilage “butterfly graft” has also been used successfully to treat INV collapse following rhinoplasty.

Alar batten grafts have been used to treat INV and ENV collapse. These are overlay grafts placed over the posterior lateral crura and spanning to the pyriform aperture. Lateral crural strut grafts are underlay grafts attached to the undersurface of the lateral crura between the cartilage and vestibular mucosa.

Alar rim grafts are used when the ala is weak and dynamic collapse is noted with inspiration. These are nonanatomic grafts as they are placed along the alar rim where there is normally only fibrofatty tissue. These grafts may also be used to correct asymmetries caused by alar retraction.

Asymmetry of the middle third may occur when one side is concave and the other side is convex in shape. This deformity may be corrected by placing a spreader graft or onlay graft on the concave side to create symmetry. Clocking sutures and sidewall-spreading sutures have also been described to align asymmetric ULCs and a deviated dorsal septum.

Nasal Tip

The nasal tip is probably the most complex and variable region of the nose. As such, a myriad of techniques have been developed to alter tip projection and rotation. Table 75–2 shows the various techniques as they relate to projection and rotation. Details of each of the techniques are beyond the scope of this chapter but the reader may refer to the references for more information.

Nasal Base

The nasal base or width of the nose consists of the columella, nasal sill, and ala. This area of the nose is usually addressed at the end of the procedure since changes to the nasal tip may affect the amount of alar flare. A wide alar base is prevalent among certain ethnicities, such as African Americans, and surgeons should not strive to create a Caucasian nose in patients who wish to maintain their ethnicity.

The widened alar base may be a result of a widened nasal sill and/or an excessive amount of alar flaring. A nasal sill excision is indicated when the nostrils are widened and have a horizontal axis whereas a Weir excision is performed when excessive alar flaring is present. Depending upon the etiology, tissue may be excised from either area to narrow the width of the nasal base. Patients must be made aware that the technique requires an external skin excision and meticulous closure is imperative to prevent a noticeable scar.

Postoperative Care

At the end of the procedure, the nose is taped and a cast is placed to stabilize cut nasal bones and to minimize postoperative edema. If there are lacerations of the septal flaps, septal splints may be used to minimize the risk of synechiae.

Patients are given postoperative instructions to apply cold compresses for 48 hours, refrain from heavy lifting and nose blowing for 1 week, and to avoid aspirin or ibuprofen products for 2 weeks. The use of postoperative antibiotics is controversial; there is little evidence in the literature that antibiotics play a valuable role postoperatively. An antibiotic ointment applied into the nostrils help incisions to seal more quickly and keep crusts from forming. Saline nasal spray can be used as needed. Patients are evaluated within the first few days of surgery to ensure that there is no early complication of surgery, such a septal hematoma.

The nasal cast, septal splints, and all external sutures are removed after one week. Patients routinely are instructed to perform nasal pressure exercises to ensure the nasal bones heal as straight and narrow as possible. Patients are typically seen again as frequently as needed to ensure an ideal outcome and answer relevant concerns.

Complications

Rhinoplasty is one of the most difficult cosmetic procedures performed today, which is why the revision rate may be as high as 20% in primary cases and 50% in revisions. Consequently, there are numerous complications that can arise from rhinoplasty. General complications include bleeding, scarring, infection, septal perforation, and the need for revision surgery.

Dorsal irregularities may occur if the bony or cartilaginous dorsum was not precisely contoured. A rocker deformity arises when the lateral osteotomy is carried too far superiorly into the thick frontal bone. When the nasal bones are medialized, the osteotomized bony segment protrudes laterally beyond the radix. This can be corrected by performing a percutaneous osteotomy at the point of the bony irregularity. An “open sky” deformity occurs when a dorsal hump is reduced to the point where there is a gap in the midline between the nasal bones. This is both palpable and visible and is treated by performing osteotomies or filling the gap with a soft cartilage graft. A saddle-nose deformity occurs when there is not enough cartilaginous septal support in the middle third of the nose and manifests with a concavity along the dorsum (Figure 75–7a). It can also occur with over-resection of the cartilaginous septum or loss of septal cartilage as a complication of an untreated infection, hematoma, cocaine abuse, or other inflammatory or autoimmune disorder. The severity of this deformity varies but the mainstay of treatment consists of providing septal support and augmenting the nasal dorsum with the use of cartilage grafts. A pollybeak deformity is a convexity of the cartilaginous dorsum/supratip region that may be categorized into cartilaginous or soft tissue etiologies (Figure 75–7b). A cartilaginous pollybeak arises when the cartilaginous dorsum has been relatively underresected compared to the bony dorsum and is treated by reducing the cartilaginous dorsum. A soft tissue pollybeak occurs when there is excessive scar formation in the supratip region, often from overresection of the dorsum or tip in a patient with thick skin, and may be treated with steroid injections. An inverted-V deformity can occur along the nasal dorsum when the ULCs lose their attachments to the nasal bones and/or the septum and collapse inward. The collapse exposes the contour of the caudal edge of the nasal bones, which is in the shape of an upside down V. The placement of spreader grafts assists in resuspending the ULC to the septum and opening the nasal valve area.

The nasal tip being the most complex region of the nose may also be fraught with complications in the hands of inexperienced surgeons. Nasal bossae are irregular knoblike protuberances of the LLCs that cause asymmetries of the nasal tip. Bossae may occur from irregularities of the cartilages themselves or from contractive scar forces acting on weakened cartilages. A pinched tip can result when the domes are excessively narrowed via a dome division or aggressive interdomal/transdomal suturing techniques. Alar retraction may occur secondary to scarring or aggressive cephalic excision and treatment typically requires supporting the LLCs with grafts. Severe alar retraction may warrant an auricular composite graft that consists of skin and cartilage to replace the scarred vestibular mucosa.

Conclusion

Rhinoplasty is one of the most challenging and rewarding procedures performed by facial plastic surgeons. To become a masterful rhinoplasty surgeon, one must possess a profound understanding of nasal anatomy and be able to execute a variety of targeted surgical techniques. In addition, the surgeon must know which technique to implement for each individual situation to achieve consistent, superior results. This process of constantly learning what works and what does not in rhinoplasty is why even the masters observe that it is an operation that takes a lifetime to fully understand.

We would like to acknowledge Alexander L. Ramirez, MD and Corey S. Maas, MD for their contribution to this chapter in the previous editions of CDT.