CORRECTIVE RHINOPLASTY. Westminster Hospital and Stoke Mandeville Hospital

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1 CORRECTIVE RHINOPLSTY By J. P. REIDY, F.R.C.S. Westminster Hospital and Stoke Mandeville Hospital CORRECTIVE rhinoplasty implies surgical alteration of the bony and/or cartilaginous nasal skeleton, including lateral wall cartilages. It does not include removal or addition of skin cover. Broad consideration is given in this paper to the surgery of the bony nasal skeleton, and that of lateral wall cartilages, only in so far as the skeleton is altered or reduced. lthough the definition could include bone and cartilage grafts to the nose, these will be only mentioned but not discussed. The subject matter is sufficiently interesting to warrant discussion, if only to repeat what is already well known. Dieffenbach, John Roe of Rochester, N.Y., and Robert Weir, of New York City, had published papers on nasal deformities, but it is to Jacques Joseph of Berlin that credit must go for the development of this field of surgery, by devising principles and operations which hold good to-day. He published several papers and a large volume in I93I. Meanwhile, there have been numerous contributions and improvements, including those of Sheehan, Joseph Safian, ufricht, and others. There is no doubt that a defect or an abnormality of the nose is of greater concern to the owner and to the onlookers than a disfigurement elsewhere. Even the loss of an eye or an ear appears of less consequence than severe damage to the nose. Corrective rhinoplasty has always been popular with the public, but in recent years the public appears to have become more "nose conscious " than previously, and the facilities for this type of surgery have increased. In addition to the personal requirements of a patient, there is now a demand for at least evenness of appearance, which has become almost an "industrial hazard" in business, on the stage, and in television. For instance, where minor defects of nose contour can be eliminated by suitable pose and light adjustment in still photography, these same defects may show markedly under the glare of television lights and require surgical correction if the " owner" wishes to continue in business. Patients, therefore, will submit to corrective rhinoplasty for personal-reasons, and for reasons connected with business and profession, and they do so in the belief that a normal-looking nose will result, and that there will be no evidence of surgical interference. Some will demand that their nose be altered to a particular size and shape, a demand often rendered impracticable with the material offered, and it is worth while remembering that" you can't make a silk purse out of a sow's ear." In general, however, it is feasible to effect the improvement indicated. For whatever reason correction is required, the surgery must be based on training and experience and on sound judgment as to what is suitable, with some sense of artistry directed towards the final result. This form of surgery is not simple, and it is as easy to over-correct as to under-correct. 52

2 CORRECTIVE RHINOPLSTY 53 NTOMY It is worth while considering the nasal structure so that the anatomy and nomenclature are clear. The bony skeleton is formed of nasal bone and frontal process of maxilla on each side, and of central plate of ethmoid and vomer in midline (Fig. I). The cartilaginous skeleton is composed of the lateral cartilage, and the alar cartilage on each side, and the septum in the midline. The alar cartilage has a greater crus in the lateral wall of the nose and lesser crus lying on the septum. These crura are joined anteriorly at an angle, the apex, which forms part of the nose tip. Examination of a nose means, then, the consideration of its three components : NSL BONES ~TUM N SL BONE 'I "~'i ~'~t~ TERL LTER~ ~LR LR~ t LTERL FIG. I natomy of nose. Fro. 2 Over-prominent alar cartilages. the bony lateral walls and arch, the lateral wall cartilages, and the septum (cartilaginous and bony) ; and their relationship to each other. One or more of these components may be out of proportion (Fig. 2) and will call for correction, unilaterally or bilaterally. External natomy or Contour.--Within certain arbitrary limits a nose may be considered normal in size and shape. Thus in relation to the whole face in profile, the normal nose occupies approximately one-third. The nose profile may be straight or slightly curved, and its angle of elevation to the vertical may be between 3 and 35 degrees. In most normal-looking noses, the angle between columella and lip is just over 90 degrees in the male and about lo5 degrees in the female. In front view, the nose should be smooth and symmetrical from root to tip, narrow at the bony bridge, and becoming broader towards the tip. Deviations above or below these average measurements will indicate the extent of the abnormalities (Fig. 3). It should be possible, from the front, just to see into the tips (apices) of the nostrils. If the nostrils are invisible then the nose is too long and possesses a drooping tip. The pug nose, tip-tilted, will present the nostrils fully to the onlooker. TRETMENT Operative procedure may be confined to the nose tip alone, to the bony bridge alone, or may include the whole nose. Since grafts of bone and cartilage are

3 54 BRITISH JOURNL OF PLSTIC SURGERY excluded from this paper, the steps to be outlined are those of reduction of size, breadth, and length. Whatever procedure is involved, all incisions are made intranasally, and therefore some pre-operative cleansing of nasal passages and upper lip is desirable. moustache should be shaved and vibrissm within the nostrils clipped, and the airways cleansed with hydrogen peroxide the night before operation. Before operation the airways are again cleansed and packed with one strip of ribbon gauze on each side soaked in an appropriate solution of cocaine and NORML BULB-ENDED RETROUSS[~ ROUND TIP COLUNELL ROMN HEBREW WELLINGTON DEPRESSED RHINOPHYM BROKEN SYPHYLITIC NEGROID PROMINENT TiP GREEK POINTED FIG. 3 Some variations in nasal shape. adrenaline. Where hypotensive ana:sthesia is employed this packing is unnecessary. In Europe and in the United States of merica the use of local anaesthesia for nasal operations is popular. In Great Britain general ana:sthesia is commonly used with or without the use of hypotensive drugs. Simple tilting of the patient and operating table with the head up markedly reduces h~emorrhage without the need for special drugs. Hump Reduction and Infracture.--(I) Simple infracture may be performed to narrow a broad bony nasal bridge (Fig. 4). (2) Reduction of a humped nose may be combined with the infracture as a step in the preparation for insertion (later) of a graft of bone or cartilage. This is frequently indicated where there is depression of the cartilaginous bridge line following partial submucous resection, or where total submucous resection is required for a very distorted septal cartilage. Total submucous resection and hump reduction are performed together, followed in three months by the cartilage or bone graft. The details are as follows :- The intranasal incision lies between alar and lateral cartilages and extends laterally on to frontal process of maxilla (Fig. 5, and S).

$Some surgeons prefer subcutaneous dissection over the nasal bones. FIG. 4, Congenital deformity : broad nasal bridge. B, fter nasal infracture and trimming of anterior border of septal cartilage.$ C, Later : bone graft to bridge line. Hump reduction is performed with Kilner's reversed chisel or with a saw (see Fig.

C, Later : bone graft to bridge line. Hump reduction is performed with Kilner's reversed chisel or with a saw (see Fig.

4 CORRECTIVE RHINOPLSTY 55 Subperiosteal clearance of nasal bones is carried out, and the tip of the elevator is brought down along the bridge line subcutaneously to the nose tip. Some surgeons prefer subcutaneous dissection over the nasal bones. FIG. 4, Congenital deformity : broad nasal bridge. B, fter nasal infracture and trimming of anterior border of septal cartilage. C, Later : bone graft to bridge line. Hump reduction is performed with Kilner's reversed chisel or with a saw (see Fig. 6), but is preceded by division with scissors of the lateral cartilages from the midline (Fig. 5, c and D). If hump reduction is not required it is not necessary to sever the lateral cartilages from the midline, but the nasal bones can be separated on each side of the midline with a small osteotome, up as far as fronto-nasal junction.

5 5 6 BRITISH JOURNL OF PLSTIC SURGERY Saw-cuts, using Joseph's cranked nasal saws, on the lateral (Fig. 6) nasal walls are, in fact, through the fronto-nasal processes of the maxilla:, just anterior to the inner canthal ligaments. Infracture is effected by thumb pressure. Drains may be inserted through the intranasal incisions to lie between nasal bones and the overlying soft tissues, together with tulle gras packs or solid rubber plugs in the nasal airways, for forty-eight hours. n external splint is made of cotton bandage soaked in collodion, applied in FIG. 6 Fig. 5.--Hump reduction., Intranasal, intercartilaginous incision. ~'B, Subperiosteal clearance of nasal bone. C, Division of lateral cartilage from septum in midline. D, Outline of incisions. FIG. 5 Fig. 6.--, Reduction of bony hump with saw. B, Lateral saw-cut through frontal process of maxilla. layers over the whole nose and including a strip of soft metal for extra rigidity. This splint remains for seven days. Splinting can also be applied using plaster of Paris or stent composition. The tulle gras plugs and the drains are removed in forty-eight hours, and thereafter the patient has nasal inhalations twice daily of Friar's balsam, followed by intranasal drops of menthol, eucalyptus, and liquid paraffin in equal parts. The subperiosteal clearance of the nasal bones is invariably followed by " black eyes " to some degree. The patient should be forewarned of this and encouraged, immediately after operation, to bathe the swollen eyelids very frequently with iced boracic lotion, witch hazel, or tincture of arnica. The discoloration may persist from five to ten days. Normal nose-blowing is not permitted for at least three weeks following intranasal incisions, lest surgical emphysema should follow.

6 CORRECTIVE RHINOPLSTY 57 When the nasal splint is removed on the fifth or seventh day there is usually some swelling present, the greater and noticeable part of which disappears in the following week. Nasal inhalations may be continued daily until the airways remain clear. The nasal bones become firmly united in three to four weeks. CROSS. SECTION OF LR CRTILGES CROSS SECTION OF LTERL CRTILGES NRROWING TIP B FIG. 7 Safian flap., Cross-sections of nose. B, Incisions in alar cartilage. LOWERING T4P B C FIG. 8 Safian flap procedure. ~ Outline of intranasal incisions. B~ Intranasal view. C, Cross-section. SEPTUM FIG. 9 "Window view" of septum--alar cartilage removed. pproximate position for removal of wedge from inferior border of septum. General Reduetion.--The nose may be reduced in all dimensions by alteration of the bony and cartilaginous skeleton. The untouched nasal skin covering eventually shrinks on to the new skeletal form. In addition, therefore, to reduction of the profile line and narrowing of the bony bridge by infracture, there may be narrowing of the nose tip, lowering of the nose tip, and shortening of the nose length. It is convenient at this point to consider the Safian flap (Fig. 7) by which

5 8 BRITISH JOURNL OF PLSTIC SURGERY the nose tip is lowered or narrowed, or both.

The tip of the flap lies in the apex of the alar cartilage, and includes more or less of the apex according to whether the nose tip is to be lowered or narrowed.

Shortening of the nose is effected by removal of an inverted wedge of septal cartilage and mucosa from its inferior border after transfixion through the B FIG.

7 5 8 BRITISH JOURNL OF PLSTIC SURGERY the nose tip is lowered or narrowed, or both. This flap consists of part of the alar cartilage with its intranasal lining, based laterally towards the alar base. The tip of the flap lies in the apex of the alar cartilage, and includes more or less of the apex according to whether the nose tip is to be lowered or narrowed. n appropriate portion of the distal end of the Safian flap is excised to achieve the desired alteration (Fig. 8). Shortening of the nose is effected by removal of an inverted wedge of septal cartilage and mucosa from its inferior border after transfixion through the B FIG. io, Result of overmarked S.M.R. B, Shortening of nose to correct depression. membranous septum (Fig. 9). This shortening of the central partition of the nose must be balanced by suitable shortening of the lateral walls, at the expense of upper border of greater crus of alar cartilage (right and left), or of the inferior border of the lateral cartilage (Fig. to). In a general nasal reduction it is convenient to make all incisions at the

8 CORRECTIVE RHINOPLSTY 59 beginning, and then to proceed with the excisions (Fig. I I). In this routine the steps are as follows :-- I. Transfixion through membranous septum. 2. Intranasal incisions between alar and lateral cartilages (or through alar cartilage parallel to its upper border, leaving a rim of alar cartilage attached to lateral cartilage above). This intranasal (vestibular) incision is carried from the lateral nasal wall forwards to the apex of the nasal passage and then distally to the nose tip, through alar cartilage, and it meets the anterior end of the transfixion incision, i.e., on septal wall or in apex of alar cartilage. This incision forms both / i I ' VESTIBULR INCISION COLUMELL TRNSFIXED C FIG. I2 Fig. I x.--general reduction., Outline of intended incisions. B, Columellar transfixion. C, Intercartilaginous incision. D, Subperiosteal clearance of nasal bone. Fig. IZ.--Subperiosteal clearance of nasal bone. Position of elevator. FIG. I I the upper and distal margins of the Safian flap. The inferior margin of the Safian flap is made by incision just within the nostril margin at about its mid-length, carried forwards to (see Fig. 8) meet the previous incisions at the apex of the alar cartilage. 3. The bony nasal hump is now cleared subperiosteally, and the elevator carried distally between skin and anterior border of septal cartilage until it runs into the columellar transfixion incisions (Figs. I I and x2). 4. The lateral cartilages may be divided from the septum close to the midline, or a little away from the midline, leaving a piece attached to the septum corresponding in amount with that to be removed from the bony hump (see Fig. 5). 5. The bony hump is cut through horizontally with the reversed chisel, saw, or osteotome, and the line of incision may be continued into the cartilaginous

$The nasal bones are infractured, either on a broad base as already described, or in " Continental" fashion, bringing the lateral saw-cut well forward on to the bridge line (Fig. I3). 6.$ The nose is shortened by excision of wedge from inferior border of septum (Fig. I4). 7. The nose tip is narrowed and/or lowered by the Safian flap procedure NSL IR PSSGES....! Fx~.

The nose is shortened by excision of wedge from inferior border of septum (Fig. I4). 7. The nose tip is narrowed and/or lowered by the Safian flap procedure NSL IR PSSGES....! Fx~.

7)- The amount of cartilage to be removed from alar cartilage is predetermined, and pressure on the nose tip will show if the " spring" has indeed been removed.

9 60 BRITISH JOURNL OF PLSTIC SURGERY hump with straight scissors from below. The nasal bones are infractured, either on a broad base as already described, or in " Continental" fashion, bringing the lateral saw-cut well forward on to the bridge line (Fig. I3). 6. The nose is shortened by excision of wedge from inferior border of septum (Fig. I4). 7. The nose tip is narrowed and/or lowered by the Safian flap procedure NSL IR PSSGES....! Fx~. r 4 saw COT IN NSL ~'ONE~...~. FIG. 13 Fig. I3.--, Reduction of hump with saw. B, Saw-cut in frontal process of maxilla. C, Saw-cut in nasal bone. Figs. I4 and IS.--General reduction of nose. FIG. 15 (see Fig. 7)- The amount of cartilage to be removed from alar cartilage is predetermined, and pressure on the nose tip will show if the " spring" has indeed been removed. The skin cover may still give the pre-operative appearance, and it is a grave mistake to go on reducing the alar cartilage by further partial excisions in order to gain the desired appearance on the table. Once the proper predetermined excision has been done, the end result will be achieved by the subsequent fibrosis during the following two to three weeks.

CORRECTIVE RHINOPLSTY 61 8. The columella transfixion incision is stitched with plain catgut; if necessary, sliding the columella forwards on the septum.

10 CORRECTIVE RHINOPLSTY The columella transfixion incision is stitched with plain catgut; if necessary, sliding the columella forwards on the septum. 9- The inferior border of the lateral cartilage is trimmed on each side, thus shortening the lateral walls equally with the septum. IO. Drains and tulle gras packs are inserted, and an external nasal collodion/gauze/metal splint is applied (Fig. 15). The after-treatment follows that already noted. nose tip which has been reduced feels hard like a bit of cardboard for about three months, and some degree of tenderness is present for several weeks. COMPLICTIONS Surgical Emphysema.--When the packs have been removed from the nasal airways, these become blocked again in a few hours by reason of intranasal oedema which takes four to five days to subside, assisted by nasal inhalations and drops. The patient must be a mouth-breather for this period, which is therefore the most uncomfortable part of the proceeding, and he must be sternly warned against blowing his nose in the usual way by grasping the tip. The risk is that of " surgical emphysema " over the bony bridge by air being forced through the intranasal incisions into the subcutaneous space. Much of the " air swelling " can be reduced by pressure, but there is also h~ematoma and risk of infection. H,ematoma.--Hmmatoma under the nasal skin is an ever-present risk, which may arise after the nasal splint has been applied and when the patient has left the theatre. Various techniques have been followed to reduce this risk, and they include simple tilting of the patient, feet down, on the operating table ; the injection locally of 1:8o,ooo adrenaline solution with or without hyalase; the use of adrenoxyl to reduce capillary bleeding, and the use of hypotensive drugs. Simple tilting of the table has been just as effective as hypotension in reducing ha:morrhage during operation and in warding off post-operative hmmatoma formation. The value of adrenoxyl is still under investigation. Hmmatoma formation may be severe enough to push off the nasal splint. On the other hand, fluctuation around the nasal bridge is usually discovered only when the splint is removed on the seventh day. To evacuate the collection of blood, the nasal passages should be carefully and thoroughly cleansed with peroxide and cetavlon, and a probe passed through the intranasal incision on each side into the subcutaneous space over the bony bridge. Pressure outside the nose will help to evacuate the blood. n external splint should be applied and the procedure repeated daily as necessary. Infection.mOne of the risks of removal of the nasal splint on the seventh day and sending the patient home is that the increased activity may produce a marked swelling of the nose. Despite this the patient may not return for inspection for several days, and by that time the subcutaneous hrematoma (for such it is) is now an abscess. This should be evacuated intranasally, and on no account should it be allowed to point through the skin at the side of the nose.

$infracture--thickening of$

11 62 BRITISH JO,L OF PLSTIC SURGERY Fig. 16, Broad.... nose following boxmg lnlunes. B, fter infracture--thickening of bony bridge. Fig Full nasal reduction. FIG. 16 FI~. x7

CORRECTIVE RHII~ ~STY 63 Intranasal dhesions.mn adhesion can and will form where an incision on the lateral wall of the nasal airway lies opposite an incision or tear in the septal mucosa.

12 CORRECTIVE RHII~ ~STY 63 Intranasal dhesions.mn adhesion can and will form where an incision on the lateral wall of the nasal airway lies opposite an incision or tear in the septal mucosa. Daily passage for several days of a glass rod smeared with liquid paraffin will reduce this risk. Black Eyes.--These have already been mentioned. They occur to greater or less degree with any dissection around the bony nasal bridge. The swelling and bruising of the eyelids can be reduced by frequent bathing with iced lotions. Residual Broadness of Bony Bridge.-- ha:matoma of bony bridge which has been allowed to persist and to organise will remain as a very broad bridge for months. Occasionally in adolescents, infracture has been followed several weeks later by gross thickening of the bony bridge as though by formation of new subperiosteal bone (Fig. 16). This may persist for months, and the temptation to repeat the infracture is difficult to resist. Bridge Line Irregularity.--Imperfect reduction of bony or cartilage bridge line may result in the appearance, on occasion, of a small irregularity in the profile of the nose a few weeks later. This is due to a small fragment of bone or cartilage left behind and becoming palpable and/or visible when the swelling of the nose has subsided. There is no alternative but to remove it surgically. Nasal Swelling.--In general, it can be said that the gross post-operative nasal swelling goes in about two to three weeks, followed by an imperceptible streamlining during the next three months, during which the nose tip feels hard like a piece of cardboard and is a little tender on gentle pressure (Fig. 17). In two cases nasal reduction has been followed by an increase in size of the whole nasal tip by a subcutaneous hard swelling. This has persisted for more than eighteen months, and proved to be dense fibrosis. The aid of the radiotherapist has been sought. Miss Susan Robinson, Medical rtist at the West Middlesex Hospital, made the drawings, and Mr R. G. Mason, Photographer at Stoke Mandeville Hospital, has been responsible for the photography. To both of them I am deeply indebted.

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