Preserving normal nasal function and controlling COSMETIC

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1 COSMETIC Dorsal Aesthetic Lines in Rhinoplasty: A Quantitative Outcome-Based Assessment of the Component Dorsal Reduction Technique Ali Mojallal, M.D., Ph.D. Da Ouyang, M.D. Michel Saint-Cyr, M.D. Nam Bui, M.D. Spencer A. Brown, Ph.D. Rod J. Rohrich, M.D. Lyon, France; and Dallas, Texas Background: Preservation or reconstruction of the middle nasal vault structure and internal nasal valve after dorsal reduction is challenging. The purpose of this study was to retrospectively analyze a series of 100 consecutive rhinoplasty cases with respect to preservation or restoration of the dorsal nasal lines following component dorsal reduction. A new quantitative mathematical application for subject digital images was performed. Methods: Medical information and digital images were obtained from 100 consecutive primary rhinoplasty patients from one author (R.J.R.) with University of Texas Southwestern Medical Center Institutional Review Board consent. All postoperative subject digital images were taken at more than 1-year follow-up. Preoperative and postoperative digital images of the dorsal nasal aesthetic lines were analyzed using a software application that quantitated various facial anatomical features compared with landmark measurements unique for each subject (pupil-to-pupil distance). Dorsal line symmetry, nose width, and variation of deformities on each side of the face were determined. Results: Mean subject dorsal line symmetry was 68 percent preoperatively and 94 percent postoperatively. Only 32.5 percent of dorsal lines were harmonious preoperatively, whereas 97 percent of dorsal lines were harmonious postoperatively. Identification of dorsal lines postoperatively versus preoperatively was similar in 74.6 percent, improved in 15.7 percent, and decreased in 9.7 percent. Nasal width lines were similar in 36 subjects, 21 subjects had wider nasal width lines, and 43 subjects had narrower width lines after surgery. Conclusions: Component dorsal hump reduction procedures result in reliable and reproducible clinical outcomes. Quantitative assessments provide evidence that improved and harmonious curves of dorsal aesthetic lines are achievable. (Plast. Reconstr. Surg. 128: 280, 2011.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. From the Department of Plastic, Aesthetic, and Reconstructive Surgery, Edouard Herriot Hospital, and the Department of Plastic Surgery, University of Texas Southwestern Medical Center. Received for publication March 18, 2009; accepted September 15, Presented at the 53rd Annual Congress of the French Society of Aesthetic Plastic and Reconstructive Surgery (SoFCPRE), in Paris, France, November 24 through 26, Copyright 2011 by the American Society of Plastic Surgeons DOI: /PRS.0b013e318218fc2d Preserving normal nasal function and controlling aesthetic outcome following rhinoplasty have been the focus of many reports. The preservation or reconstruction of the middle nasal vault structure and internal nasal valve after dorsal reduction has evolved through several techniques. 1 9 With the reduction of the bony pyramid width and medialization of the upper lateral cartilages, middle nasal vault narrowing and internal valve collapse may result. Subsequent significant nasal obstruction occurs and a poor aesthetic outcome may be achieved. In addition, over time, small irregularities of the dorsal aesthetic lines that include depressions, breaks, pinching, shadows, or deviations have been reported. To achieve proper dorsal nasal lines and airway function, the authors have used the component dorsal reduction technique for over 10 Disclosure: The authors have no financial interest in this research project or in any of the techniques or equipment used in this study. The authors have no conflicts of interest to disclose

2 Volume 128, Number 1 Dorsal Aesthetic Lines in Rhinoplasty years. 1 With the component dorsal reduction technique, the transverse portion of the upper lateral cartilage, which is a critical structure in defining the dorsal aesthetic lines and in establishing the nasal valve angle, is preserved. 1,2 The purpose of this study was to retrospectively analyze a series of 100 consecutive rhinoplasty cases from the senior author (R.J.R.) with respect to preservation or restoration of the dorsal nasal lines following dorsal hump reduction and to compare the outcomes of primary rhinoplasties focusing on the dorsal nasal aesthetic lines. A new mathematical tool for rhinoplasty analyses was applied to quantitate facial anatomical regions preoperatively and postoperatively. PATIENTS AND METHODS The Institutional Review Board for Human Subjects at the University of Texas Southwestern Medical Center approved the procurement of medical records and digital images from 100 consecutive primary rhinoplasty patients (80 women and 20 men) from January of 2006 to August of All patients had undergone an open rhinoplasty approach. Eighteen patients had a deviated nose before surgery. Inclusion criteria consisted of primary rhinoplasty, a complete medical record with preoperative and postoperative standardized photographs, absence of nasal airway obstruction before surgery, absence of trauma, and a minimum of 12 months follow-up. Component Dorsal Hump Reduction Technique The fusiform nasal hump is formed by the nasal bones, the dorsal portion of the septal cartilage, and the upper lateral cartilages, with variations in osseous and cartilaginous composition. In this technique, five essential steps were followed: (1) separation of the upper lateral cartilages from the septum with conservation of the horizontal part of the upper lateral cartilages; (2) incremental reduction of the septum proper; (3) incremental dorsal bony reduction (using a rasp); (4) verification by palpation; and (5) final modifications, if indicated (spreader grafts, suturing techniques, osteotomies). Dorsal Aesthetic Lines Dorsal aesthetic lines were defined as originating on the supraorbital ridges, traversing medially along the glabellar area, converging at the medial canthal ligaments, diverging at the keystone area, and terminating at the nasal tip. Dorsal aesthetic lines of the nose were defined by the topography of the frontal bone, by the nasal bones, and by the upper lateral cartilages. Computer Program for Outcome Analyses of Dorsal Aesthetic Lines A computer software program was developed to quantitate characteristics of dorsal aesthetic lines using point data analysis. Data from preoperative and postoperative digital images were analyzed based on the following four variables: x axis, y axis, interpupillary distance, and interphiltral distance (between distal extremities of philtral columns) (Fig. 1). Specifically, a first set of points were marked on the medial canthi and a horizontal line intersecting both points generated the x axis. A second set of points were marked at the middle of the brows and at the middle on the upper lip to generate the y axis. The standardized measurements avoided inaccuracies caused by head tilting. A third set of points in the middle of each pupil was marked to define the interpupillary distance. This served as the denominator for analyzing all measurements as a ratio to eliminate the risk of error caused by variations in the size of the images. Using a ratio for each subject also allows for analysis of measurements among all subject data sets. Two points were placed at the origin (supraorbital ridges) and two points were placed at the end. The software program divided the distances evenly between these endpoints, and the dorsal aesthetic lines were drawn manually. The same person set the points in all of the analyses and according to the same criteria. No significant interreader variation was observed with three blinded readers in dorsal aesthetic line measurements using digital images of 15 subjects. Analysis of Dorsal Aesthetic Lines Quantitative assessments included preoperative and postoperative symmetry between two dorsal lines, the shape of each dorsal line, and dorsal aesthetic line width ( 1 percent) at the keystone level. The presence and number of contour deformities (e.g., inverted V) or discontinuities in dorsal aesthetic lines were recorded. Nonquantitative information was collected on the effects of dorsal aesthetic line skin light reflections between preoperative and postoperative digital images. The dorsal aesthetic line width to interphiltral width ratio was determined in each digital image at three different levels. Statistical Analysis Standard statistical descriptive analyses for each anatomical data set were performed. Non- 281

3 Plastic and Reconstructive Surgery July 2011 Fig. 1. Example of defining x and y axes and interpupillary distance. Points 1 and 2 were assigned in medial canthi for the x axis, whereas points 3 and 4 were assigned for the determination of the y axis. Points 5 and 6 were assigned for the interpupillary distance used as a common denominator. For all images, each red data point had a designated blue number. parametric data sets were analyzed using the Wilcoxon matched-pairs signed ranks test to compare whether the members of a pair differ in size, with statistical significance defined as p RESULTS Subjects The mean age of the patients was 35.3 years (range, 18 to 59 years) in the 100 subjects examined. The average follow-up examination occurred at 18.9 months, with a range of 14 to 34 months. Thirty-nine cases had a dorsal hump reduction greater than 5 mm and 61 patients had a dorsal hump reduction of less than 5 mm. Eighteen subjects had a nasal deviation before surgery, and no recurrences were observed at the last postoperative follow-up. Dorsal Aesthetic Line Symmetry Before surgery, 69 percent of the subjects had symmetrical dorsal aesthetic line measurements between two dorsal lines. Postoperative assessments demonstrated that 94 percent of the subjects had symmetrical dorsal aesthetic lines (p 0.001). Dorsal Aesthetic Line Harmony Among 200 dorsal aesthetic lines analyzed in 100 subjects, 32.5 percent (n 65 lines) were harmonious before surgery and 97.0 percent (n 194 lines) were harmonious after surgery (p 0.001). The results included two subjects with unilateral dorsal aesthetic line deformities that included discontinuities of one subject at the level of the keystone area and a second subject at the intercanthal level. Dorsal Aesthetic Line Keystone Width The postoperative average dorsal aesthetic line keystone width change was percent (range, 27.7 to 31.7 percent) (Fig. 2). In seven patients, dorsal aesthetic line keystone width was similar ( 1 percent) after surgery ( similar group ); three of these subjects (42.8 percent) had dorsal hump reductions greater than 5 mm (Fig. 3). In 33 cases, dorsal aesthetic line keystone width was increased by more than 1 percent after surgery ( wider group ), among which 16 cases (47.1 percent) had a dorsal hump reduction greater than 5 mm (Fig. 4). In 59 cases, dorsal aesthetic line keystone width was decreased more than 1 percent after surgery ( narrower group ), among which 19 cases (32.2 percent) had a dorsal hump reduction greater than 5 mm (Fig. 5). Medical records review did not find the use of a spreader graft. Dorsal Aesthetic Line Width to Interphiltral Width Ratio The mean presurgical dorsal aesthetic line width to interphiltral width ratio was examined at three different levels of the nose (Table 1). The dorsal aesthetic line width to interphiltral width ratio was 85.5 percent at the level of the intercanthal line and 88.3 percent at the level of the keystone area. The dorsal aesthetic line width to 282

4 Volume 128, Number 1 Dorsal Aesthetic Lines in Rhinoplasty Fig. 2. Distribution of dorsal aesthetic line keystone width change after surgery. interphiltral width ratio was percent at the level of the tip-defining points (Table 2). The mean postsurgical dorsal aesthetic line width to interphiltral width ratio was examined at three different levels of the nose. The dorsal aesthetic line width to interphiltral width ratio was 82.7 percent at the level of the intercanthal line and 83.2 percent at the level of the keystone area. The dorsal aesthetic line width to interphiltral width ratio was 98.9 percent at the level of tip-defining points. Effect on Dorsal Aesthetic Line Light Reflection Visibility of dorsal aesthetic lines on preoperative and postoperative digital images was similar in 62 patients (74.6 percent), whereas in 13 patients (15.7 percent) dorsal aesthetic lines were more visible in the postoperative digital images than in the preoperative images. In eight cases (9.7 percent), the dorsal aesthetic lines were more visible on preoperative digital images than on postoperative images. Seventeen patients were excluded for dorsal aesthetic line light reflection assessment because of differences in skin brightness before and after surgery (Table 1). DISCUSSION Over the past several decades, the trend in aesthetic rhinoplasty has been to be conservative and limit resection in favor of realignment and reshaping, to preserve anatomy and function. This is the first outcome study, to the best of our knowledge, using objective computer analyses of the dorsal aesthetic lines. All patients were examined at more than 1 year after surgery. Our results of 100 consecutive patients operated on using the component dorsal reduction technique demonstrated safety and efficacy for improving the dorsal aesthetic lines. The software evaluation of dorsal aesthetic lines before and after rhinoplasty provided quantitative assessments of nasal anatomy from many different levels. Using two curved lines inputted manually, the software program was developed to generate curves that were analyzed further. To compare intrasubject measurements, a common denominator of the interpupillary distance was used. This allowed for comparison of data sets between all subjects. The strength of this evaluation is the clinical determination of dorsal aesthetic lines by the same person and according to the same criteria and directly marking the lines in a software-readable format for subsequent analysis. In addition, no significant interreader variation was observed (data not shown). The successful use of this quantitative method requires a limited number of criteria to be reliable and easily performed. Subjects must be photographed under standardized lighting conditions and head position. Increased precision can be achieved by zooming in the digital images to maximize the dorsal aesthetic line identification. Using a denominator that remains invariable from preoperative to postoperative photographs allows analyzing all distances as a ratio. Using a ratio eliminates the risk or error inherent in a variation of the photograph s size and permits an interindividual comparison. The weakness of this system is that points have to be selected visually and set manually. That is why it has to be performed by an experienced examiner and needs to be validated before any analyses. Our major findings using this quantitative approach showed the following: 283

5 Plastic and Reconstructive Surgery July 2011 Fig. 3. A patient from the similar group is shown. Dorsal aesthetic lines were harmonious before surgery (left, above and below) and after surgery (center, above and below). The dorsal aesthetic line keystone width was identical after surgery (0.6 percent). Dorsal aesthetic line width to interphiltral width ratios were 61.9, 68.6, and 73.8 percent, respectively, at the intercanthal, keystone, and nasal tip levels before surgery; and 58.4, 71.8, and 70.6 percent, respectively, after surgery. The software-generated quantitative report is also shown (right). 1. Postsurgical dorsal aesthetic line symmetry (94 percent) was improved dramatically compared with preoperative dorsal aesthetic line symmetry levels. 2. Harmony or smoothness levels of the dorsal aesthetic lines were likewise improved on postsurgical analysis (two cases of postsurgical discontinuous dorsal aesthetic lines were observed that resulted in unilateral inverted-v deformities). 3. Evaluation of keystone widths demonstrated a wide range of widths among our subjects; our data demonstrated that with a dorsal hump reduction greater than 5 mm, 41 percent of subjects were associated with the wider group compared with 28 percent when the dorsal hump reduction was less than 5 mm. 4. When the interphiltral distance is used to measure the forefront of concrete philtrum, we observed that the dorsal aesthetic line 284

6 Volume 128, Number 1 Dorsal Aesthetic Lines in Rhinoplasty Fig. 4. A patient from the wider group is shown. Dorsal aesthetic lines were symmetrical and had a harmonious shape before (left, above and below) and after surgery (center, above and below). The dorsal aesthetic line keystone width increased 15.6 percent after surgery. The dorsal aesthetic line width to interphiltral width ratios were, respectively, 79.1, 65.9, and 80.6 percent at the intercanthal, keystone, and nasal tip before surgery; and 80.7, 76.6, and 81.2 percent after rhinoplasty. The software-generated quantitative report is also shown (right). widths were highly conserved along the length of the entire nose before surgery (85.5 to percent) and after surgery (82.7 to 98.9 percent). To the best of our knowledge, this is the first study that reports this ratio at different levels in a significant number of subjects. Anatomically, the nasal midvault presents a complex structure consisting of bone, cartilage, and soft tissues. The midvault of the nose is formed by the two upper lateral cartilages and the septal cartilage with a T configuration at their junction, which is important for their stability. This part constitutes the internal nasal valve, which is composed of the septum medially, the caudal end of the upper lateral cartilage laterally, and the inferior turbinate inferolaterally. This 285

7 Plastic and Reconstructive Surgery July 2011 Fig. 5. A patient from the narrower group is shown. Dorsal aesthetic lines were symmetrical before (left, above and below) and also after surgery (center, above and below). There was a decrease of the dorsal aesthetic line keystone width of 21.7 percent. However, dorsal aesthetic lines were not harmonious before surgery, whereas dorsal aesthetic lines were harmonious after surgery. The dorsal aesthetic line width to interphiltral width ratio was 106.1, 136.6, and percent at the intercanthal, keystone, and nasal tip, respectively, before surgery; and 108.1, 106.9, and percent, respectively, after rhinoplasty. The software-generated quantitative report is also shown (right). valve has an anatomical angle of 10 to 15 degrees and a normal cross-sectional area of 55 to 83 mm 2 and is the site of highest nasal resistance. 10 It functions as the primary regulator of airflow, providing physiologic resistance and the sensation of normal nasal airway patency. 11 The middle third of the nose contributes also to define the dorsal aesthetic lines of the nose, which are created by the contour of the frontal bone, nasal bones, and after the keystone area by the upper lateral cartilages. The middle third of the nose is a fragile area and can be easily destabilized during rhinoplasty and result in both functional and cosmetic disorders. Traditionally, dorsal reduction has been considered a simple part of rhinoplasty, in contrast to nasal tip refinement. The en bloc composite dorsal reduction is the predominant cause of collapse of the upper lateral cartilages. 2 Other surgical ma- 286

8 Volume 128, Number 1 Dorsal Aesthetic Lines in Rhinoplasty Table 1. Preoperative and Postoperative Dorsal Aesthetic Line Keystone Width Change Dorsal Hump Reduction Narrower (< 1%) DAL Keystone Width Change Groups Similar ( 1% to 1%) Wider (>1%) Total 5 mm mm Total DAL, dorsal aesthetic lines. Table 2. Dorsal Aesthetic Line Width to Interphiltral Width Ratio at Three Different Levels of the Nose DAL Width to Interphiltral Width Ratio Intercanthal (%) Keystone (%) Tip-Defining Points (%) Preoperative Postoperative DAL, dorsal aesthetic line. neuvers that can increase its risk of subsequent collapse include the following: cephalic resection of the lateral crura of the lower lateral cartilages, which can disrupt the link between the lower and upper lateral cartilages, and lateral osteotomies that medialize the upper lateral cartilages. All of these maneuvers may leave the sidewall of the nose unsupported and lead to functional and cosmetic problems. 12,13 The collapse of the nasal sidewalls can create an inverted-v deformity and can decrease nasal airflow by collapse of the internal valve. 14 Risks for developing midvault collapse include short nasal bones with primarily cartilaginous dorsal hump, thin dorsal skin, flaccid upper lateral cartilages, limited deviation of the nasal dorsum, and narrow midvault. 4,14,15 Different techniques have been described to restore the midvault Originally, these techniques were described for secondary rhinoplasty but are now advocated by many authors for primary rhinoplasty. This quantitative outcome analysis has demonstrated the safety and efficacy of the component dorsal reduction technique. The keys to this technique are the formation of bilateral submucoperichondrial tunnels before sharp separation of the upper lateral cartilages from the central septum, and a graduated approach to dorsal hump reduction starting with the cartilaginous septal hump followed by the bony hump. This allows maximal preservation of the integrity of the upper lateral cartilages and preservation of the mucosa of the internal valves, which helps prevent cicatricial stenosis and subsequent nasal airway obstruction. Furthermore, their role in creating and maintaining the dorsal aesthetic lines is crucial to the aesthetics of the nasal dorsum. 1,2 Intraoperatively, if more definition in a thick-skinned patient is required, a horizontal mattress suture proximal and distal using 5-0 polydioxanone is added to stabilize the upper lateral cartilages to the septum. In case of a thin-skinned patient with a fine dorsal aesthetic line width, slight tension is added distally with a simple 5-0 polydioxanone suture through the upper lateral cartilages and the anterior septal angle to properly align the edges and make them symmetrical. CONCLUSIONS Component dorsal hump reduction represents a reliable and reproducible technique with long-lasting results. The software program described offers the opportunity to quantitate outcomes from different plastic surgery procedures using only two-dimensional digital images. Comparison between different techniques can now be measured quantitatively and can provide a powerful tool with which to determine and improve outcomes in rhinoplasty. Ali Mojallal, M.D. Department of Plastic Aesthetic and Reconstructive Surgery University of Lyon Edouard Herriot Hospital Place d Arsonval Lyon, Cedex 03, France dr.mojallal@gmail.com PATIENT CONSENT Patients provided written consent for the use of their images. REFERENCES 1. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump reduction: The importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg. 2004;114: ; discussion Tebbetts JB. Primary modification of the dorsum. In: Tebbetts JB, ed. Primary Rhinoplasty: A New Approach to the Logic and the Techniques. St. Louis, Mo: Mosby; 1998: Hall JA, Peters MD, Hilger PA. Modification of the Skoog dorsal reduction for preservation of the middle nasal vault. Arch Facial Plast Surg. 2004;6: Boccieri A, Macro C, Pascali M. The use of spreader grafts in primary rhinoplasty. Ann Plast Surg. 2005;55: Ishida J, Ishida LC, Ishida LH, Vieira JC, Ferreira MC. Treatment of the nasal hump with preservation of the cartilaginous framework. Plast Reconstr Surg. 1999;3: ; discussion Arslan E, Aksoy A. Upper lateral cartilage-sparing component dorsal hump reduction in primary rhinoplasty. Laryngoscope 2007;117:

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