1 British Journal of Plastic Surgery (2003), 56, q 2003 The British Association of Plastic Surgeons. Published by Elsevier Science Ltd. All rights reserved. doi: /s (03) The upper buccal sulcus approach, an alternative for post-trauma rhinoplasty Christian Vacher, Joao J. Accioli de Vasconcellos* and Jonathan A. Britto *Department of Maxillo-Facial Surgery, Hôpital Beaujon, AP-HP, Department of Anatomy, University of Paris VII (Bichat), and Institute of Anatomy, Paris, France; Hôpital Necker, Paris, France SUMMARY. We suggest that it is possible to correct the stigmata of the post-traumatic nasal deformity by means of an upper buccal sulcus approach alone. This approach is demonstrated in a series of ten cadaveric subjects for the correction of nasal skeletal deviation or bossing. Furthermore, the technique, which avoids internal nasal scarring and violation of the internal nasal valve, has been successfully employed in four patients with a minimum of 9 months follow-up. We suggest that it is possible to conserve the internal nasal valve and avoid problems of nasal tip retractions using this approach in selected cases. q 2003 The British Association of Plastic Surgeons. Published by Elsevier Science Ltd. All rights reserved. Keywords: rhinoplasty, maxillofacial trauma. In post-trauma rhinoplasties, the patients are not looking for a completely different nose. However, deformities may affect the morphology of the pyramid and nasal physiology, and require corrections for aesthetic or functional reasons. Aesthetic concerns include deviation of the nose usually without tip malposition. Functional concerns may include air flow obstruction in conjunction with these deformities. Internal nasal approaches result in scarring and scar retraction may compromise nasal air flow. 1 Traditional techniques of rhinoplasty make an internal nasal incision and approach the nasal skeleton with obligate disruption to the nasal valve. The aim of this anatomic and clinical study is to determine if it is absolutely necessary, in post traumatic cases, to make a nasal incision. Materials and methods Anatomy Ten rhinoplasties were performed on fresh cadavers with a dorsal hump in eight cases and a deviation in six cases (Fig. 1). An upper buccal sulcus approach was used (as in Le Fort 1 osteotomy but mucosal incision from canine to canine only) which allowed: (1) a sub-periosteal dissection of the anterior nasal spine, and the approach to the piriform fossa, (2) a sub-perichondral dissection of the nasal septum, (3) the resection of a small strip of nasal septum at its superior edge, just below the nasal dorsum (Fig. 2), (4) lateral osteotomies under direct vision, (5) impaction and reposition of the intact nasal pyramid to correct the dorsal hump and any deviation (Fig. 3) After cadaveric rhinoplasty, the nasal skin was resected, to study the muscles and the cartilages of the nose after surgery. The tip of the nose was resected to measure the angle between nasal septum and the upper lateral cartilage. Aïach has determined that nasal valve function should be preserved when possible, and that the optimum angle between septum and the upper lateral cartilage is normally ten to fifteen degrees. 2 Case reports Two patients who needed a post-trauma rhinoplasty are presented from a short series of four. Case 1. A 21-year-old woman previously involved in a road traffic accident and having sustained a nasal bone fracture had undergone three rhinoplasties by conventional nasal approaches. She presented complaining of a dorsal hump. A fourth rhinoplasty by an upper buccal sulcus approach was, therefore, undertaken and the dorsal hump was corrected by the impaction of the intact nasal pyramid (Figs 4 6). Case 2. A 27-year-old man presented for primary rhinoplasty following a motorcycle accident. Despite a nasal bone reduction in the emergency room, the nasal pyramid remained impacted and deviated. The upper buccal sulcus approach was used and a subperichondrial dissection of the nasal septum allowed the harvest of a septal graft. A subcutaneous dissection of the columella was undertaken to approach the supra tip region and the septal graft was inserted. The deviation of the nose was corrected by lateral osteotomies as in case one and reposition of the intact nasal pyramid (Figs 7 10). 218
2 The upper buccal sulcus approach, an alternative for post-trauma rhinoplasty 219 Figure 1 Fresh cadaver before dissection, displaying deviation (1A-AP view) and dorsal hump (1B-lateral view). Results Cadaveric study In fresh cadavers, in all cases, the intra-canine upper buccal sulcus approach gave a very good vision of the whole nasal septum, and the caudal part of the lateral osteotomies was also possible under direct vision. When the dorsum remained convex after impaction of the pyramid (2 cases), cartilage grafting of the supra tip was possible by subcutaneous columellar dissection from the oral approach (Fig. 11). After resection of the skin, the muscles and the cartilages of the tip were intact in all cases. The mean angle between the nasal septum and the lateral cartilage of the nose was ^ (Table 1). Clinical study Two patients are presented, with nine months and one year follow-up, respectively. A further two patients declined follow-up. The two patients shown illustrate Table 1 Details of the cadaveric rhinoplasties Cadaver Sex/ age Nasal deviation Dorsal hump Dorsal graft Nasal valve angle Figure 2 Sub-periosteal dissection of the anterior nasal spine, sub perichondrial dissection of septum and nasal septal resection. Osteotome placed in piriform fossa in preparation for lateral osteotomy. 1 F/83 2 þ F/70 2 þ F/58 þ M/65 þ þ F/71 2 þ þ M/69 2 þ M/61 þ M/68 þ þ M/63 þ þ F/72 þ þ þ 15
3 220 British Journal of Plastic Surgery Figure 3 AP (3A) and lateral (3B) views of the same cadaver after rhinoplasty by an upper buccal sulcus approach, showing correction of deviation and dorsal hump. Figure 4 Case one: preoperative views. The patient presented complaining of a dorsal hump despite three conventional rhinoplasties. There is also a deviation to the left.
4 The upper buccal sulcus approach, an alternative for post-trauma rhinoplasty 221 Figure 5 Case one: anterior view. Upper buccal sulcus approach, showing septal resection. Figure 7 Case two: preoperative AP view of the second patient. Deviation of the dorsum. that dorsal hump and nasal deviation resulting from a trauma can be successfully treated from the buccal approach alone. Discussion The upper buccal sulcus approach is a well established means of surgical access to the middle third of the face in craniofacial and orthognathic surgery. It is not commonly used in the UK for access for corrective nasal surgery. The upper buccal sulcus approach for nasal surgery has been used by Kim and Kim, with the aid of an endoscope 3 to perform lateral nasal osteotomies of the frontal processes of the maxilla. We have not found it necessary to use an endoscope to achieve safe and complete nasal disjunction. Furthermore, to achieve adequate cosmesis, Kim and Kim found it necessary to use intranasal incisions in conjunction with the buccal approach, thereby violating the nasal valve and Figure 6 Case one: postoperative views. The dorsal hump was corrected by the impaction of the intact nasal pyramid and the nose is straight.
5 222 British Journal of Plastic Surgery Figure 8 Case two: lateral preoperative view. The dorsal hump is evident. Figure 10 Case two: lateral postoperative view. Correction of dorsal hump is evident. introducing intranasal scar. Apart from the use of the endoscope, the combined approach described by Kim and Kim is exactly that described by Wayoff in France 32 years before. 4 We have sought to avoid the violation of the internal nasal valve and the introduction of internal nasal scarring, by using only the upper buccal sulcus approach and have restricted our clinical use to post-traumatic cases only. In these cases, disruption of the nasal skeleton and not the tip anatomy is usually at issue. Nasal impaction by this approach allows the correction of nasal skeletal deviation. Gola 5,6 described success with this manoeuvre, via endonasal incisions. We have found that dorsal impaction of the intact nasal pyramid can be combined with supra tip cartilage graft, using the upper buccal sulcus approach alone. The supra tip region is approached with a subcutaneous columellar dissection. Figure 9 Case two: postoperative view. The deviation was corrected by the asymmetric impaction of the intact nasal pyramid and a dorsal cartilaginous graft. Figure 11 In a fresh cadaver, cartilage grafting of the supra-tip by a subcutaneous columellar dissection from the oral approach.
6 The upper buccal sulcus approach, an alternative for post-trauma rhinoplasty 223 The introduction of a graft is, therefore, achieved without intra-nasal incision or transgressing the intra-nasal valve. Thus, successful skeletal correction of the nose in selected cases can be achieved with minimal disruption of the tip-supratip structures and no endonasal incision. References 1. Wayoff M. Quelques vérités premières sur l anatomie et la physiologie de la pyramide nasale. J F Otorlinolarggugol Audiophonol Chir Maxillofac 1969;18: Aïach G, Levignac J. La rhinoplastie esthétique. Paris: Masson; Kim JT, Kim ST. Endoscopically assisted, intraorally approached corrective rhinoplasty. Plast Reconstr Surg 2001;108: Wayoff M, Perrin C. Mobilisation globale de la pyramide nasale selon Cottle: ses possibilités dans la chirurgie fonctionnelle du nez. Acta Otorhinolaryngol Belg 1968;22: Gola R, Nerini A, Laurent-Fyon C, Waller PY. Rhinoplastie conservatrice de l auvent nasal. Ann Chir Plast Esthet 1989;34: Gola R. Rhinoplastie conservatrice. Ann Chir Plast Esthet 1994;38: The Authors Christian Vacher MD, PhD Chef de Service of Maxillo-facial Surgery, Hôpital Beaujon, AP-HP, 100 Bd Général Leclerc, Clichy, France and Maître de conférence in Anatomy, Faculté Bichat (Paris VII), Paris, France Joao J. Accioli de Vasconcellos MD Visiting fellow in Plastic Surgery; Brasil Jonathan A. Britto BSc, MB, MD, FRCS(Plast) SpR in Plastic Surgery; Royal Free and University College Hospitals; London, UK Correspondence to Dr Christian Vacher Paper received 29 May Accepted 15 April 2003.