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Intraoperative Considerations
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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.
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There are a variety of incisions that vary with the approach that allow the surgeon to access the septum, LLC, ULC, and nasal bones.
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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.
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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.
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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.
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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).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Middle Third and Nasal Valves
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.