Primary Open Rhinoplasty

Transcription

1 Rhinoplasty Continuing Medical Education Article Primary Open Rhinoplasty Aesthetic Surgery Journal 2016, Vol 36(9) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: DOI: /asj/sjw093 Arash Momeni, MD; and Ronald P. Gruber, MD Abstract Rhinoplasty is perhaps the most complex cosmetic surgery procedure performed today. It is characterized by an intricate interplay between form and function, with patient satisfaction being dependent not only on improvement of nasal appearance but also resolution of preexisting airway symptoms. The prerequisite for successful execution of this challenging procedure is a thorough understanding of nasal anatomy and physiology. Hence, a thorough preoperative evaluation is at least as important and the surgical skill in performing the operation. Establishing an accurate diagnosis through a comprehensive nasal analysis is obligatory. As to the surgical approach, much has been written about the advantages and disadvantages of closed vs open rhinoplasty. The more commonly chosen open approach has numerous advantages, including improved visualization without distortion, thus, enabling precise diagnosis and correction of deformities. While the surgical treatment of existing nasal deformities is tailored to the needs of the individual patient, the authors have noted a total of 10 essential components to form the foundation for successful technical execution of rhinoplasty. These include: (1) septoturbinotomy; (2) opening the nose; (3) humpectomy/spreader flaps; (4) tip-plasty; (5) supratip-plasty; (6) columellar strut; (7) dorsal augmentation; (8) nasal base reduction; (9) osteotomies; and (10) rim grafts. Postoperative, a variety of problems, such as edema, may be successfully addressed without surgical intervention. Diligent postoperative management is critical in ensuring a positive patient experience. Finally, a comprehensive understanding of possible postoperative complications, such as bleeding, ecchymosis, edema, and persistent or new iatrogenic deformity is mandatory prior to offering rhinoplasty to patients. Accepted for publication April 14, LEARNING OBJECTIVES The reader is presumed to have a basic understanding of rhinoplasty procedures. After reading this article, the reader should be able to: (1) Identify a patient who is suitable to undergo rhinoplasty and perform a comprehensive preoperative nasal analysis. (2) Discuss surgical techniques that form the foundation for successful execution of rhinoplasty. (3) Discuss postoperative management and complications after rhinoplasty. American Society for Aesthetic Plastic Surgery (ASAPS) members and Aesthetic Surgery Journal (ASJ) subscribers can complete this CME examination online by logging on to the CME portion of ASJ swebsite( org) and then searching for the examination by subject or publication date. Physicians may earn 1 AMA PRA Category 1 Credit by successfully completing the examination based on this article. Rhinoplasty is perhaps the most complex cosmetic surgery procedure performed today. 1 Despite the incredible challenge of obtaining reproducible results, it continues to be among the top 5 cosmetic surgery procedures in the United States, with 145,909 procedures being performed in In almost no other area in cosmetic surgery is there such an intricate interplay between form and function, with patient satisfaction being dependent not only on improvement of nasal appearance but also resolution of preexisting airway symptoms. Dr. Momeni is an Assistant Professor of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA. Dr Gruber is an Adjunct Associate Clinical Professor, Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA; and an Associate Clinical Professor, Division of Plastic and Reconstructive Surgery, The University of California, San Francisco, San Francisco, CA. Corresponding Author: Dr Ronald P. Gruber, 3318 Elm Street, Oakland, CA 94609, USA. rgrubermd@hotmail.com

2 984 Aesthetic Surgery Journal 36(9) The prerequisite for successful execution of this challenging procedure is a thorough understanding of nasal anatomy and physiology, which represents the foundation of being able to accurately diagnose existing deformities and determine a comprehensive treatment plan. Over the past 2 decades, we have witnessed a paradigm shift in our approach to rhinoplasty; away from ablative procedures to restoration of structural support and correction of contour deformities. 3-7 PREOPERATIVE EVALUATION The importance of a thorough preoperative assessment, which should be comprehensive and extend beyond the physical examination alone, cannot be overstated. Assessing patient expectations and correlating them with the extent of nasal pathology provides insight regarding the psychological stability and suitability of the patient to undergo the procedure. The patient should be encouraged to share and prioritize what aspects of the nasal shape and function are of concern. Vague concerns and general complaints are not particularly helpful for establishing a viable treatment plan. The preoperative consultation should be viewed as an opportunity to not only establish reasonable expectations and congruent goals with the patient, but also to identify patients not suitable to undergo surgery, such as those who are seeking rhinoplasty due to external pressures as well as those with preexisting personality disorders. 8 The common occurrence of psychiatric disorders in patients seeking rhinoplasty is well known. While the prevalence of body dysmorphic disorder ranges between 0.7 to 3 percent in community samples, 9-11 up to 43 percent of patients seeking aesthetic rhinoplasty have been demonstrated to have at least moderate symptoms of body dysmorphic disorder. 12 In addition to reviewing the patient s past medical history, it is critical to obtain a thorough nasal history. Mandatory components include preexisting allergic disorders, vasomotor rhinitis, nasal trauma, prior nasal procedures, as well as airway problems and sinus pathology. 13,14 The patient should be encouraged to disclose the use of illicit drugs (eg, cocaine), as these not only complicate the procedure but also have the propensity to compromise the postoperative result. 15 Finally, a review of current medications, such as non-steroidal antiinflammatory drugs and acetylsalicylic acid, and herbal supplements is important to identify agents that increase the risk of intra- and postoperative bleeding. NASAL ANALYSIS Performing a comprehensive nasal analysis requires a thorough understanding of the underlying nasal anatomy. It is important to realize that the nose should never be evaluated in isolation but rather in conjunction with a full facial analysis. Given the multitude of factors influencing the Table 1. Views Required as Part of a Comprehensive Nasal Analysis View Deformity (examples) Frontal General Deviation Asymmetry of dorsal aesthetic lines Upper third Middle third Lower third Asymmetry Narrow Wide Inverted-V deformity Narrow Wide Wide alar base Notching of alar rims Lateral General Long vs short nose Basal Upper third Middle third Lower third Acute vs obtuse nasofrontal angle Osseous hump Cartilaginous hump Saddle nose Over- vs under-projection of tip Hanging vs retracted ala/columella Pollybeak deformity Nostril asymmetries Alar flaring Abnormality of columellar-lobule ratio outcome after rhinoplasty, a systematic approach to preoperative analysis is prudent. 16 Assessment of frontal, lateral, and basal views is considered standard, particularly, as certain deformities may only be visible on a single view (Table 1). Hence, omission of any of these views harbors the danger of missing critical findings that, if not addressed intraoperatively, hamper the postoperative result. For practical purposes, we further divide the nose into thirds (ie, upper, middle, and lower third), and analyze these areas individually, as it allows us to tailor the procedure to the site of the pathology. While the frontal and basal views allow evaluation of symmetry and width of the nose, the lateral view reveals the dorsal line, tip location and projection, as well as morphology of the nostrils. Remember that while the components of the analysis should be standardized, cultural differences and ethnic preferences should be acknowledged Ideal facial and nasal proportions have been described by a variety of authors with a full review being beyond the scope of this article

3 Momeni and Gruber 985 Not only are nasal and facial proportions analyzed, but also nasal skin thickness assessed. Skin thickness varies considerably between patients but also within individuals. Skin overlying the upper one-third of the nose is typically thinner and more mobile than the thick sebaceous skin overlying the lower third. This distinction has practical implications as thicker skin requires more extensive alteration of the underlying framework and is associated with prolonged postoperative edema. 3,27,28 Nasal palpation is an essential part of the nasal examination. It helps to establish the size and position of the nasal bones, as well as to identify the intrinsic strength of the lower nose, thus providing information as to whether cartilage grafts are needed for support. A Cottle maneuver may identify the need for placement of spreader grafts. Finally, every preoperative evaluation mandates an intranasal inspection to evaluate the septum, inferior turbinates, as well as nasal valves. Performing this evaluation before and after administration of a vasoconstrincting agent is helpful to unmask pathologies amenable to medical management alone. The purpose of a systematic approach to nasal analysis is to establish an accurate diagnosis as well as to determine a customized treatment plan. The patient should be informed about all exam findings for the purpose of a better understanding of the planned procedure. STANDARDIZED IMAGING Proper surgical planning requires preoperative photographs using standardization regarding technique, lighting, and views. 29,30 The latter should include frontal, oblique, lateral, and basal views to allow for accurate planning and comparative postoperative analysis. The use of modern imaging software is particularly useful for patient education, preoperative planning, as well as setting appropriate expectations. While it is a form of mock surgery, it is important to highlight that digitally altered images do not guarantee a result but rather represent a goal to work toward. 30,31 Theconservativeuseof digital imaging software can aid in demonstrating physical changes that are difficult to verbalize and can, thus, ensure that the patient and surgeon are in agreement about the goals of the procedure prior to entering the operating room. SURGICAL APPROACH Much has been written about the advantages and disadvantages of closed vs open rhinoplasty While the closed approach has the advantage of leaving no external scar, requiring less dissection with resultant decreased edema formation, and being associated with decreased operative times, it requires a greater degree of experience, as the visibility of the nasal framework is limited. Furthermore, indications for the closed approach are more limited, such as for correction of isolated deformities of the nasal tip or dorsum. 37 The more commonly chosen open approach has numerous advantages, including improved visualization without distortion, thus enabling precise diagnosis and correction of deformities. 3,38,39 The improved exposure facilitates resident education as simultaneous visualization of the anatomy and planned maneuvers is possible. Disadvantages of the open approach include prolonged edema, extended surgical time, frequent need for additional stabilization of the cartilaginous framework, as well as an external transcolumellar scar. 3,38 The latter, however, is typically well concealed and rarely an area of concern. 40,41 While surgical treatment of existing nasal deformities is tailored to the needs of the individual patient, the authors have noted a total of 10 essential components to form the foundation for successful technical execution of rhinoplasty. These include: (1) septoturbinotomy; (2) opening the nose; (3) humpectomy/spreader flaps; (4) tip-plasty; (5) supratipplasty; (6) columellar strut; (7) dorsal augmentation; (8) nasal base reduction; (9) osteotomies; and (10) rim grafts. Septoturbinotomy The inferior turbinates are a common site of nasal airway obstruction with soft tissue/mucosal hypertrophy and/or osseous hypertrophy being possible causes. Given the various causes, it is not surprising that a multitude of different treatment options exist for management. 14,42-44 In an attempt to avoid a more radical surgical approach, Tanna et al developed a noninvasive maneuver, the so-called septoturbinotomy, which is a quick and simple maneuver performed prior to any other part of the rhinoplasty procedure. 45 After infiltration of the turbinates and bony septum with local anesthetic with epinephrine, a nasal speculum (3 inches in length) with wide blades is inserted into the vestibule until the entire instrument is within the nasal vault (Video 1). For themaneuvertobesuccessful,thebladesofthespeculum need to be placed along the vomerine ridge as well as the inferior turbinate. Once inserted completely, the handles are compressed, thus opening the blades with a resultant audible out-fracture of the inferior turbinate, centralization of the bony septum, and resultant marked improvement of the nasal airway. Incomplete insertion may result in skin and soft tissue injury around the nostrils. A modification of this maneuver, in which a large clamp is used, has been termed the reverse nutcracker. 45 While the authors perform this maneuver in the vast majority of cases, surgeons should refrain from performing this procedure in cases in which septal cartilage grafts are needed, as septal cartilage fracture may be associated with this maneuver.

4 986 Aesthetic Surgery Journal 36(9) Opening the Nose The authors preference is an inverted-v transcolumellar incision along with an infracartilaginous incision, although a stair-step incision may be used, depending on the surgeon s preference (Video 2). Atraumatic technique and careful dissection is particularly critical when making the transcolumellar incision with subsequent elevation of the columellar flap in order to avoid injury to the underlying medial crura of the lower lateral cartilages as well as unnecessary trauma to the delicate columellar skin. Retraction is provided exclusively with skin hooks without utilization of forceps so as to not crush the tissues. After visualization of the lower lateral cartilages the skin and soft tissues are reflected superiorly. Humpectomy/Spreader Flaps A nasal hump, whenever present, is one of the most common causes of distress. Despite the obvious deformity, however, simple humpectomy may result in numerous problems, including disruption of the dorsal aesthetic lines, middle vault collapse, and inverted-v deformity. 46 While the traditional approach to management of a dorsal hump was a composite resection that resulted in little control over the amount of upper lateral cartilage resected, modern approaches entail a more controlled/incremental reduction. 47,48 Spreader grafts are commonly used to reconstruct disrupted dorsal aesthetic lines and middle vault collapse. The authors, however, more commonly perform spreader flaps in their practice, which is an approach numerous other authors have discussed with some variation Following a small intercartilaginous incision at the level of the anterior septal angle, a Freer or Cottle elevator is used to create submucoperichondrial tunnels. A proportional increase of spreader flap mobility is noted with increasing degrees of mucoperichondrial elevation. It is critical to avoid injury to the mucosa so as to prevent synechiae formation with resultant narrowing of the internal nasal valve. After sharp release of the upper lateral cartilages (ULC) from the dorsal septum up to the level of the bone, the ULC is disarticulated from the nasal bone by following its course under the nasal bone in the Keystone area, yet, paying particular attention to keep it intact. Next, the lower end of the ULC is grasped with a clamp, folded medially, and secured in placed with 5-0 PDS mattress sutures (Video 3). Execution of these steps prior to performing the humpectomy results in protection of the ULC with prevention of inadvertent resection. Next, the bony dorsum is reduced, either with an osteotome or a rasp, depending on the degree of reduction desired. Finally, the spreader flaps are re-suspended to the septum with mattress sutures. Tip-plasty The evolution of tip-plasty has paralleled a trend noted in other areas of rhinoplasty, namely away from ablative maneuvers and towards cartilage-preserving techniques. This is reflected in the development of suture techniques for tip modification. 5,53,54 However, creating a well-defined and narrow tip while avoiding the problems of a pinched tip with a concave lateral crus is rather challenging. Four sutures comprise the bases of suture-based tipplasty, namely: (1) transdomal; (2) interdomal; (3) lateral crural mattress; and (4) columella-septal suture. Dome-defining sutures or transdomal sutures have been used, for example, to treat a broad nasal tip Subsequent modifications to alleviate the occasional pinched tip appearance have been suggested. 5,58 The issue of inadequate eversion of the lateral crus with rim collapse, however, is most elegantly addressed by means of the hemi-transdomal suture. 59 Using this approach the cephalic end of the dome is adequately reduced while ensuring adequate lateral crus eversion. While the superior aspect of the dome is adequately narrowed subsequent to accurate placement of a hemitransdomal suture, minimal to no narrowing of the inferior aspect of the dome and lack of lateral crus concavity is seen. In contrast, a poorly placed transdomal suture is associated with narrowing of the entire dome and concavity of the rim (Figure 1). The hemi-transdomal suture is indeed a simple suture, which narrows the upper half of the dome, reduces tip width, and everts the rim, thus preventing rim collapse. Next, any existing asymmetry between the respective domes is addressed by means of a domal equalization suture (ie, inter-domal suture). 60 A particularly challenging task is correction of nasal tip convexity. While cephalic trim is helpful in improving the appearance, further maneuvers are typically necessary to permit adequate correction of the deformity. The authors preferred approach for this task is the use of a lateral crus mattress suture, a technique that can also be used to correct existing convexities of cartilage grafts This technique corrects any residual lateral crus convexity, substitutes for a lateral crural spanning suture, lengthens the lateral crus, thus increasing tip projection, and typically obviates the need for a lateral crural strut graft (Video 4). Finally, the columellarseptal suture secures the tip to the caudal septum. Suprartip-plasty A common problem post-rhinoplasty is related to maintaining a well-defined appearance of the nose on frontal view. The observation that the lateral crura have a tendency to splay laterally with resultant broadening of the nasal tip, made further technical refinements necessary to counteract this tendency. Ideally, a procedure would allow correction of any existing lateral crus convexity, maintain an entirely

5 Momeni and Gruber 987 Figure 1. Intraoperative images (A, C) and illustrations (B, D) of a hemi-transdomal suture. Note adequate narrowing of the dome along with eversion of the lower border of the lateral crus in this 43-year-old woman. In contrast, narrowing of the entire dome and concavity of the rim is associated with a poorly placed transdomal suture. cartilaginous tip, that would prevent alar retraction, as well as prevent lateral displacement of the lateral crura. 64 Conceptually, our preferred supratip-plasty approach preserves the cephalic portion of the lateral crus that is normally discarded. It, furthermore, secures the tip cartilages in a manner that prevents splaying of the lateral crus and postoperative tip widening. The procedure entails a series of 5 steps (Video 5) that include: (1) incision of the cephalic lateral crus; (2) undermining of the cephalic edge of the lateral crus: (3) straightening of the lateral crus using sutures; (4) slipping the cephalic cartilage island under the lip of lateral crus; and (5) securing the tip complex to the dorsum. Columellar Strut The columellar strut graft is a very powerful tool to control tip projection and strength. The most common source is typically septal cartilage, however, rib cartilage may be used as well. Indications for placement of a columellar strut graft include: (1) under-projected tip; (2) weak tip; and (3) asymmetric tip. Video 6 demonstrates the technique of placing and securing a columellar strut graft. Dorsal Augmentation Deficiencies of the nasal dorsum have been treated by a wide variety of graft materials We have implemented a simple algorithm that determines the source of graft material based on the amount of augmentation necessary. In cases in which only a minor degree of augmentation is indicated, our preferred approach is to use septal cartilage. 66,69 Medial and large augmentations are best performed with Surgicel- or fascia-wrapped diced cartilage Whenever additional structural support is warranted, the use of rib cartilage is paramount. 15,73,74 Our preference is to wrap diced cartilage in deep temporal fascia, which is harvested via a vertical termporal scalp incision. Next, silicone dorsal nasal sizers are used to estimate the amount of graft necessary to achieve the desired correction. The cartilage graft is then cut into 1 mm pieces,

6 988 Aesthetic Surgery Journal 36(9) Figure 2. This 45-year-old woman underwent primary rhinoplasty consisting of tip-plasty, humpectomy, triangular rim graft, columellar strut, as well as deprojection of the nose via middle crus resection. (A, C, E) Preoperative and (B, D, F) 11-month postoperative photographs are included. placed in the fascia, and rolled into a structure resembling the dimensions of the silicone sizer (Video 7). Nasal Base Reduction A wide nasal base is not an uncommon abnormality. Correction of this abnormality can be achieved in one of two ways, namely: (1) alar base or sil excision; or (2) alar release and interalar sutures. While the former approach may be performed in primary rhinoplasty, caution is warranted in patients presenting for secondary rhinoplasty as further skin excision may result in stenotic nostrils. In these patients, alar release and interalar suture placement allows adequate correction of the abnormality without being associated with iatrogenic soft tissue deficiency. 75 The ala is released from its maxillary attachments, including the pyriform ligament, via a buccal incision (Video 8). 76 Next, a 2-0 non-absorbable monofilament suture is used to pass from the dermis of one ala to that of the other. It is important to ensure that the knots are not placed too close to the skin surface as palpability and extrusion may ensue. Nasal Osteotomy While a comprehensive discussion of the various techniques of nasal osteotomy is beyond the scope of this article, several key concepts deserve mentioning. The choice of osteotomy technique is determined by the existing nasal abnormality. A simple classification of broad nasal bones is helpful in guiding the surgeon to choose the proper technique for correction. It is based on the dimensions of the nasal base and dorsum.

7 Momeni and Gruber 989 Figure 3. This 44-year-old man underwent primary rhinoplasty including humpectomy, tip-plasty, caudal shortening, septoplasty, and columellar strut placement. (A, C, E) Preoperative and (B, D, F) 14-month postoperative photographs are included. A type I nose is characterized by a broad nasal base only and is best corrected by a low-to-low (lateral) osteotomy, which allows movement of the largest segment of nasal bone. A type II nose is characterized by a broad nasal base and dorsum and requires lateral as well as a medial oblique osteotomy. Following this maneuver the nasal bone is attached superiorly, with the superior ends of the osteotomies being about 2 to 5 mm apart. A type III, which is best treated by a medial oblique osteotomy, is characterized by a broad dorsum only. 77 contour graft may be sufficient. 58,79,80 While visibility of alar grafts can be a problem, reconstruction of the lateral crus anatomically by means of an anatomic graft can alleviate this risk. Based on the concepts introduced by Daniel, a triangular shaped cartilage graft, sutured end-to-end to the lower border of the lateral crus, can help address a variety of alar rim deformities (Video 8). 81 Figures 2 and 3 demonstrate two clinical cases in which a combination of the aforementioned procedures were performed. Alar Rim Grafts Alar rim deformities not only represent an aesthetic concern, but can also pose functional problems (eg, inspiratory airway obstruction secondary to collapse). In many cases of a weak lateral crus, a lateral crural strut graft as proposed by Gunter is the treatment of choice. 78 In less severe cases with minor alar rim deformities an alar rim POSTOPERATIVE CARE The goal of diligent postoperative management is to prevent postoperative problems, thus, enhancing the patient experience and improving satisfaction. While some residual deformities may require secondary procedures, a variety of problems may be successfully addressed without surgical intervention.

8 990 Aesthetic Surgery Journal 36(9) An important point to consider is that the immediate postoperative period is characterized by significant anxiety. Three different patient responses can be expected upon removal of the nasal splint and first inspection in the mirror; the patient may be pleased, dissatisfied, or have a flat/ delayed expression. 82 The use of flesh-colored tape immediately upon splint removal has been demonstrated to result in subjective improvement during the immediate postoperative period in the latter two patient groups. 82 Belek and Gruber explain the beneficial effects of this simple intervention by the fact that the nose is only partially exposed, thus, permitting the patient to gradually adjust to the appearance of the altered nose. 82 While the beneficial effects of postoperative nasal taping could be attributed to merely covering nasal edema and ecchymosis, the use of nasal tape can be a far more powerful tool in controlling nasal shape postoperatively. The concept of orthorhinotics represents an adaptation of principles of orthodontics and describes the use of nasal tape and nasal cones to address common early post-rhinoplasty problems. 83 Postoperative findings of supra-tip fullness, residual crookedness, increased tip edema, as well as nostril deformities may be successfully treated using this approach. 83 POSTOPERATIVE COMPLICATIONS Postoperative complications after rhinoplasty include bleeding, ecchymosis, edema, and persistent or new iatrogenic deformity. The latter may even result in worsening of nasal airway obstruction. While sound knowledge of anatomy can aid in preventing some of the structural complications (ie, deformities), intra- and perioperative blood pressure control can help in minimizing the risk of postoperative epistaxis. Management of postoperative epistaxis is determined by the severity of bleeding. While mild postoperative bleeding from the incision line may be successfully treated with head elevation and gentle pressure, more severe bleeding requires additional interventions. These may range from administration of intranasal vasoconstrictors invasive procedures such as intranasal packing and cauterization. An interesting approach to management of excessive postoperative bleeding is the use of desmopressin, a synthetic analog of the antidiuretic hormone L-arginine vasopressin. 84 Its mechanism of action is an increase in endothelial factor VIII, thus, increasing coagulation activity. Successful control of excessive postoperative bleeding following intravenous administration of desmopressin has been reported. 84 CONCLUSION Rhinoplasty continues to be perhaps the most complex cosmetic surgery procedure performed today. Keys to success are a thorough preoperative analysis with establishment of a diagnosis and execution of an individualized procedure tailored to the specific anatomic abnormalities and concerns of the patient. The modern approach to rhinoplasty is characterized by cartilage preservation and incremental changes to the cartilage and bony framework. Supplementary Material This article contains supplementary material located online at Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Neaman KC, Boettcher AK, Do VH, Mulder C, Baca M, Renucci JD, VanderWoude DL. Cosmetic rhinoplasty: revision rates revisited. Aesthet Surg J. 2013;33(1): Cosmetic Surgery National Data Bank Statistics. Aesthet Surg J. 2015;35(Suppl 2): Rohrich RJ, Ahmad J. Rhinoplasty. 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