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Flashcards in 59 Rhinoplasty & Nasal Reconstruction Deck (27):
1

What is rhinoplasty?

What is rhinoplasty?

Rhinoplasty is a challenging surgical operation used to change the functional performance and aesthetic appearance of the nose through manipulation of bone, cartilage, and soft tissue.

2

How common is rhinoplasty?

How common is rhinoplasty?

Rhinoplasty is the most frequently performed operation in the field of facial plastic and reconstructive surgery. In 2012, approximately 240,000 rhinoplasty surgeries were performed in the United States.

3

Who tends to undergo rhinoplasty?

Who tends to undergo rhinoplasty?

An estimated 80% of rhinoplasty surgeries are performed on women, though it is the second most common facial plastic surgery performed in that group (facelift is the most common). Conversely, rhinoplasty is the most common procedure performed in men, though they represent only 20% of all rhinoplasty patients. Rhinoplasty is most common in the 22- to 34-year-old age group (44% of all), followed by the 35- to 60-year-old age group (31% of all).

4

Why is rhinoplasty considered a challenging operation?

Why is rhinoplasty considered a challenging operation?

There are few surgical procedures in which the perception of success rests so substantially on the abilities of the surgeon. In cosmetic rhinoplasty, millimeter changes make the difference between a satisfactory and a disappointing outcome. Rhinoplasty, therefore, requires a collaborative exploration of what the patient would consider an appropriate result and how his or her expectations match surgical realities. The surgeon must have experience with numerous rhinoplasty techniques and a thorough grasp of nasal anatomy (Figures 59-1 and 59-2). The success or failure of rhinoplasty depends on the interplay of the patient’s unique nasal anatomy and comorbidities, the surgeon’s experience and ability, and the patient’s preparation regarding realistic outcomes.

5

How does one “analyze” the nose preoperatively for rhinoplasty?

How does one “analyze” the nose preoperatively for rhinoplasty?

While a comprehensive discussion of preoperative nasal analysis is beyond the scope of this chapter, there are several general points worth mentioning. Every initial rhinoplasty consultation includes six standard preoperative rhinoplasty photos, which provide a framework to analyze the nose. These views are the frontal, right/left oblique, right/left lateral, and the basal views.

  • Frontal View: On frontal view, the nose is divided horizontally into thirds. The upper third is comprised of the nasal bones, which should be symmetric and 75% of the intercanthal distance. The middle third, also called the “midvault” is formed by the upper lateral cartilages and the dorsal septal cartilage. A line connecting the glabella to the ipsilateral tip-defining point is called the brow-tip aesthetic line. It should be curvilinear, symmetric, and smooth along the midvault. Deformities from trauma or prior surgery disrupt the brow-tip aesthetic line. A narrow middle third suggests the presence of nasal valve dysfunction (see Question 9). Nasal tip shape may be characterized as bulbous, narrow, bifid, boxy, or amorphous. The elegant tip forms a diamond shape with two tip-defining points, which are identified by the light reflex they produce. The tip-defining points are ideally separated by less than 1 cm. Finally, the nostril rims should form a “gull-in-flight” relationship with the columella.
  • Lateral View: The lateral view provides assessment of the profile of the nose and also the ala-tip complex. On lateral view, the length of the ala and tip should be roughly equal and there should be 2 to 4 mm of columella showing below the level of the nostril rim. The elegant nasal tip profile has a “double break” produced by (1) the tip-defining point and (2) a subtle angulation at the junction of the tip lobule with the columella. Additionally, a supratip break should be present between the nasal tip and the nasal dorsum.
  • Basal View: The basal view is used to assess nasal base width and nasal tip symmetry. On basal view, the nose should form an equilateral triangle. The width of the columella compared to the width of the lobule should be 2 : 1. The tip should comprise one third of the total height, while the nostrils make up the remaining two thirds on basal view.

6

How does nasal tip rotation differ from nasal tip projection?

How does nasal tip rotation differ from nasal tip projection?

  • Tip Rotation: Rotational movement of the position of the tip along an arc formed from a fixed point at the superior tragus
  • Tip Projection: The anterior or posterior positioning of the nasal tip relative to the midface

7

On the lateral view, the nasofrontal, nasolabial, and nasofacial aesthetic angles can be created based on the geometry of the nose.

Define them.

On the lateral view, the nasofrontal, nasolabial, and nasofacial aesthetic angles can be created based on the geometry of the nose. Define them.

  • Nasofrontal Angle: Intersection of a line connecting the glabella and sellion and a line tangent to the nasal dorsum (ideal 115 to 130 degrees)
  • Nasolabial Angle: Intersection of a line tangent to the columella and a line tangent to the upper lip, which forms a vertex at the subnasale (ideal 90 to 95 degrees in males and 95° to 110° in females)
  • Nasofacial Angle: Intersection of a line tangent to the nasal dorsum with a line from the glabella to the soft tissue pogonion (ideal 36 to 40 degrees)

8

What is Goode’s ratio?

What is Goode’s ratio?

Goode’s ratio is a means by which to measure the anterior projection of the nasal tip. Goode’s method of assessing tip projection takes into account the relationship between nasal length and the alar groove. On lateral view, a vertical line is drawn from the sellion (the posterior-most soft tissue point at the root of the nose) through the alar groove. The amount of tip projection is determined by then dropping a perpendicular second line from the tip-defining point to the first line. Nasal length is determined using a line from the sellion to the tip-defining point. The ideal ratio of tip projection to nasal length using the Goode method is 0.55 : 1 to 0.6 : 1.

9

What is the internal nasal valve and why is it functionally important?

What is the internal nasal valve and why is it functionally important?

The internal nasal valve is approximately 1 cm posterior to the nostril aperture and is comprised of the septum, the upper lateral cartilage, and the nasal floor. The angle between the upper lateral cartilage and the septum is acute at this location and is susceptible to collapse. The anterior head of the inferior turbinate may crowd the internal nasal valve, though it is not strictly part of this structure. This internal nasal valve behaves like a Starling resistor in that it shuts once a threshold flow rate is reached. If the triggering flow rate is relatively low, the patient perceives difficulty breathing through the nose.

10

What is external nasal valve collapse?

What is external nasal valve collapse?

The lower lateral cartilages form incomplete rings around the nostril openings called the external nasal valve. They are designed to prevent the collapse of the soft tissue of the nose during nasal inspiration. External nasal valve collapse occurs when these cartilages provide insufficient soft tissue support during inspiration.

11

What is the Cottle maneuver?

What is the Cottle maneuver?

The Cottle maneuver is a dynamic nasal examination tool whereby the cheeks are distracted laterally, assessing for any subjective improvement in nasal airflow. This tool aids in diagnosing nasal valve incompetence.

12

How are internal and external valve collapse corrected?

How are internal and external valve collapse corrected?

Cartilage spreader grafts are classically used to correct internal nasal valve incompetence. Spreader grafts are rectangular cartilage grafts that are sutured to either side of the dorsal septum to lateralize the upper lateral cartilages. External nasal valve collapse is characteristically corrected with alar batten grafts, which are cartilage grafts placed over or under the lateral crus cartilages to provide greater stability.

13

What are the major and minor support mechanisms for the nasal tip?

What are the major and minor support mechanisms for the nasal tip?

Major (3)

  • Size, strength, and resiliency of the lower lateral cartilages
  • Attachments of the lower lateral cartilages to the septum at the medial crural footplate
  • Attachments of the lateral crura of the lower lateral cartilages to the upper lateral cartilages, known as the scroll region

Minor (6)

  • Interdomal ligament
  • Cartilaginous dorsal septum (anterior septal angle)
  • Sesamoid complex
  • Attachment of the lower lateral cartilage to the overlying superficial musculoaponeurotic system
  • Nasal spine
  • Membranous septum

14

Describe the incisions used in open (external) rhinoplasty.

Describe the incisions used in open (external) rhinoplasty.

  • Transcolumellar: A horizontal incision made at the narrowest, most convex portion of the columella. To prevent a straight-line scar, this incision is broken up with an “inverted V” at the midline.
  • Marginal: A curvilinear incision that follows the caudal margin of the lower lateral cartilages. When combined with the transcolumellar incision, this allows the nasal tip to be degloved (Figure 59-4).

Figure:  The intercartilaginous incision (A) and marginal rim incision (B) are made on either side of the lateral crura of the alar cartilage. The intercartilaginous incision permits good access to the nasal dorsum (C).

15

Describe the incisions used in closed (endonasal) rhinoplasty.

Describe the incisions used in closed (endonasal) rhinoplasty.

  • Intercartilaginous: Placed between the lower lateral and upper lateral cartilage to gain access to the nasal dorsum (Figure 59-4). These incisions may be extended medially to the septum and continued as a hemitransfixion or full transfixion incision for access to the septum.
  • Transcartilaginous: A variant of the intercartilaginous incision. The transcartilaginous incision is made several millimeters caudal to the junction of the upper and lower lateral cartilages. The incision is carried through the overlying cartilage, which is then removed as a cephalic trim (see Question 19). The transcartilaginous incision allows for a conservative volume reduction of the lateral crus of the lower lateral cartilage.

16

What are the advantages and disadvantages of the two standard rhinoplasty approaches?

What are the advantages and disadvantages of the two standard rhinoplasty approaches?

Endonasal/Closed:

  • Advantages: no external incisions, less operative time, less edema
  • Disadvantages: compromised exposure, compromised tip support

External/Open:

  • Advantages: maximum exposure, accurate placement and suturing of grafts, greater accuracy in establishing relationships between the various parts of the nose, greater visualization helpful in surgeon training
  • Disadvantages: longer operative time, more postoperative edema, external scar

17

What is the tripod concept of the nasal tip?

What is the tripod concept of the nasal tip?

The tripod concept is a simplified way to depict the structures that control the position of the domes of the nasal tip (see Figures 59-1 and 59-2). The tripod consists of:

  • The paired medial crura of the lower lateral cartilages
  • The left lateral crus of the lower lateral cartilage
  • The right lateral crus of the lower lateral cartilage

In this model, lengthening or shortening any of the members of the tripod will alter tip position.

18

How is upward tip rotation achieved?

How is upward tip rotation achieved?

Upward tip rotation can be achieved using tip suspension sutures to pull the domes or lateral crus cartilage in the cephalic direction. More subtle rotation is achieved by simply resecting cartilage from the cephalic portion of the lateral crus. Postoperative scar tissue forms in the resected void and scar contraction causes tip rotation in the cephalic direction. Cephalic rotation may also be accomplished by repositioning the lower lateral cartilages onto a graft that is attached to the caudal septum, known as a caudal septal extension graft. This nonanatomic cartilage graft provides a support structure between the medial crura, which may then be sutured in the desired position to provide increased rotation (or projection if necessary). Another method is to transect, overlap, and suture the lateral crura. This shortens these two limbs of the “tripod” and causes the domes to rotate upward. Finally, the illusion of upward tip rotation can be achieved through the blunting of the nasolabial angle using diced cartilage “plumping” grafts.

19

What is done to correct the bulbous nasal tip?

What is done to correct the bulbous nasal tip?

Volume reduction of the lobules typically requires the excision of some portion of the cephalic border of the alar cartilage, known commonly as a “cephalic trim.” The strip of lateral crus cartilage left behind is ideally kept entirely intact; that is, a “complete strip” is maintained. However, the intact strip may be cut and strategically resutured or intentionally weakened, as long as its integrity is ultimately restored. The more that the complete strip is weakened, the more severe is the potential for loss of tip support and postoperative tip asymmetry. Most surgeons believe that a minimum of 4 to 8 mm of complete strip must be preserved to avoid a significant loss of tip support. A useful and cosmetically appealing adjunct is the lateral crural strut graft, which is a 1-cm by 0.5-cm rectangular cartilage graft placed into a pocket beneath the lateral crus. This flattens the lateral crus, providing less bulbosity, and also strengthens the cartilage, which limits postoperative complications.

20

What is a dorsal hump and how is it removed, and what is an “open-roof” deformity?

What is a dorsal hump and how is it removed, and what is an “open-roof” deformity?

Both the nasal bones and the midvault cartilages contribute to dorsal humps, though the latter typically comprises more of the hump. A variety of techniques and tools have been developed to treat dorsal humps. In the case of a small dorsal hump, rasps are used to reduce the hump with fine control. Larger humps are taken down using straight osteotomes. However, removing large portions of the dorsum may lead to an “open-roof” deformity. This deformity is analogous to cutting the peak off of an A-frame house. The nasal dorsum appears widened on frontal view and the cut edges of the nasal bones may be visible through the skin. To correct an open-roof deformity, osteotomies are made at the lateral aspect of the nasal bones. The mobile nasal bones are then pushed together medially, closing the open-roof.

21

What potential complications should be discussed with the patient prior to rhinoplasty surgery?

What potential complications should be discussed with the patient prior to rhinoplasty surgery?

Bleeding, infection, scarring, septal perforation, need for further procedures, failure to improve symptoms, poor cosmetic result

22

What is a “pollybeak” deformity and how does it occur?

What is a “pollybeak” deformity and how does it occur?

The pollybeak deformity is a complication of rhinoplasty in which the postoperative appearance resembles the curved beak of a parrot because of supratip fullness. Pollybeaks are categorized by their cartilaginous or soft tissue etiologies. Cartilaginous pollybeak deformity results from loss of nasal tip support. This causes the nasal tip to descend, which allows the anterior septal angle to produce a convexity in the supratip. Soft tissue pollybeak occurs when scar tissue fills the supratip break. This may occur following overresection of the nasal dorsum with resultant dead space, especially in the patient with thick or inelastic skin. The treatment of a pollybeak depends on the etiology. Intralesional steroids may improve soft tissue pollybeak whereas tip support reconstruction may be necessary for cartilaginous pollybeak deformity.

23

What is a saddle nose deformity?

What is a saddle nose deformity?

The saddle nose deformity is a concave depression of the midvault resulting from insufficient cartilage support in the middle third of the nose. This can be caused by an untreated septal infection, septal hematoma, cocaine abuse, inflammatory or autoimmune disease, and prior surgery.

24

What is the inverted V deformity?

An inverted V deformity occurs when the upper lateral cartilages lose their attachments to the nasal bones and/or septum. This allows the cartilage to fall away from the nasal bones. The caudal edge of the nasal bones can then be seen in relief through the skin. Placement of spreader grafts resuspends the upper lateral cartilages to the septum and improves the inverted V.

What is the inverted V deformity?

An inverted V deformity occurs when the upper lateral cartilages lose their attachments to the nasal bones and/or septum. This allows the cartilage to fall away from the nasal bones. The caudal edge of the nasal bones can then be seen in relief through the skin. Placement of spreader grafts resuspends the upper lateral cartilages to the septum and improves the inverted V.

25

How long does it take to heal following rhinoplasty surgery?

How long does it take to heal following rhinoplasty surgery?

The majority of the healing following primary rhinoplasty takes place in the first 8 weeks. However, a small amount of healing takes place for up to 18 months. Soft tissue swelling may take months to resolve completely, especially following open rhinoplasty. Patients must be made aware of this fact preoperatively so that they are not disappointed by their immediate postoperative results. Numbness or sensitivity of the nasal tip skin is commonplace following rhinoplasty due to neuropraxia of the nasopalatine nerve as it travels through the incisive canal. This typically resolves over 3 to 6 months. In addition, the nasal tip will feel very stiff after surgery due to scar tissue formation. However, as the scar tissue remodels over the first 3 to 6 months the nasal tip becomes more mobile. If revisions are necessary, it is wise to wait at least 6 months between operations.

26

Which approach is superior: open or closed?

Which approach is superior: open or closed? 

Controversy

Open rhinoplasty involves degloving the nasal tip and provides optimal exposure of the nasal skeleton. Although exposure is improved, it is at the expense of greater postoperative edema. Open rhinoplasty also produces a small external columellar scar, though this is typically very well tolerated. Closed rhinoplasty involves intranasal incisions to gain access to the nasal structures through the nostrils. Exposure is limited and tip work requires “delivery” of the lower lateral cartilages for direct visualization. Although closed rhinoplasty does not produce an external scar, it disrupts more of the nasal tip support mechanisms than the open approach.

The approach utilized depends on the goals of the surgery and expertise of the surgeon. Most experienced rhinoplastic surgeons prefer and advocate one approach over the other for general rhinoplasty, but few surgeons would argue against using the closed approach for addressing minimal defects and the open approach for correcting significant, severe nasal deformities.

27 Do alloplastic implants have a role in rhinoplasty surgery? Controversy

In many situations, the availability of cartilage for grafts is limited. Alloplastic implants, though not without inherent problems, can serve an important role. The most common implants used include polymeric silicone, expanded polytetrafluoroethylene (ePTFE; Gore-Tex, W.L. Gore and Associates Inc., Flagstaff, AZ), porous high-density polyethylene (pHDPE; Mepor, Porex Technologies, Fairburn, GA), polydioxanone plate (PDS Flexible Plate, Johnson & Johnson Company, Langhorne, PA), and acellular human dermis (AlloDerm®, LifeCell Corporation, Branchburg, NJ). The surgeon must counsel patients on the increased incidence of infection and extrusion with their use when compared to autologous grafts in preoperative discussions.

27

Do alloplastic implants have a role in rhinoplasty surgery?

Do alloplastic implants have a role in rhinoplasty surgery?

Controversy

In many situations, the availability of cartilage for grafts is limited. Alloplastic implants, though not without inherent problems, can serve an important role. The most common implants used include polymeric silicone, expanded polytetrafluoroethylene (ePTFE; Gore-Tex, W.L. Gore and Associates Inc., Flagstaff, AZ), porous high-density polyethylene (pHDPE; Mepor, Porex Technologies, Fairburn, GA), polydioxanone plate (PDS Flexible Plate, Johnson & Johnson Company, Langhorne, PA), and acellular human dermis (AlloDerm®, LifeCell Corporation, Branchburg, NJ). The surgeon must counsel patients on the increased incidence of infection and extrusion with their use when compared to autologous grafts in preoperative discussions.

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