Chapter 115: Rhinoplasty

(Fig. 115.1). For Fig. 115.1, the labels are as follows: The nose comprises a bony cartilaginous framework with three components: upper, middle, and lower thirds. The upper third is formed by the paired nasal bones and nasal septum, the middle third is formed by the paired upper lateral cartilages and nasal septum, and the lower third is formed by the paired lower lateral cartilages and nasal septum. Having a good understanding of this anatomy is vital to both rhinoplasty and nasal reconstruction surgery. The nasal bones are around 2.5 cm long and are continuous with the frontal processes of the maxilla. They overlap the upper lateral cartilages for around 6 to 8 mm. At this point, the upper lateral cartilages and nasal septum join to form a T-shape construct. The upper lateral cartilages continue caudally to join with the paired lower lateral cartilages, which also overlap the upper lateral cartilages. The lower lateral cartilages have three different components: lateral, middle, and medial crura. They join with the nasal septum in the midline at the medial crus. The lower lateral cartilages are intimately related to tip projection, rotation, and definition and are usually modified during rhinoplasty. It is important to realize that the nasal alae do not contain cartilage, as the lower lateral cartilage finishes more cranially than the alae. Alar support is instead provided by the fibrous nature and shape of the alar construct.1–3 Fig. 115.1 Algorithm for correction of a deviated nose. (ULCs, upper lateral cartilages.) i v i. ii iii iv lower lateral cartilage ii. B. Upper lateral cartilage iii. A. Nasal bone iv. C. Medial crus of lower lateral cartilage v. F. Nasal septum

2. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St Louis: Quality Medical Publishing; 1998

3. Constantian M. Rhinoplasty, Craft and Magic. New York: Thieme Publishers; 2009 2. A patient with unresolving unilateral Bell’s palsy is seen in clinic, as they are experiencing problems with nasal obstruction. Paralysis of which one of the following muscles is most likely to be responsible for their symptoms? In patients with Bell’s palsy, the muscles of facial expression are paralyzed, either temporarily or permanently. A number of muscles will affect nasal obstruction in a facial palsy patient, but the levator labii superioris alaeque nasi muscle is the most important in this regard. It originates from the upper frontal process of the maxilla and inserts into the skin of the lateral nostril and upper lip. It is innervated by the buccal branch of the facial nerve and elevates the medial nasolabial fold and nasal alae. The nasalis has two components that affect nasal airway patency. There are both compressor and dilator components which cause reduction or enlargement of the nasal alae, respectively. Paralysis of this muscle will therefore also contribute to nasal obstruction in this patient, but less so than the levator labii alaeque muscle. The buccinator muscle pulls the corner of the mouth laterally and 1026 Part VII ■ Aesthetic Surgery compresses the cheek, the levator labii superioris muscle elevates the lip and midportion of the nasolabial fold, and the depressor septi nasi muscle pulls the septum inferiorly.1–3 There are a number of other potential causes of nasal obstruction with or without rhinoplasty. A recent systematic review found that common causes postrhinoplasty included collapse of the internal nasal valve, a deviated septum, and loss of mucosa to the inferior turbinate. Other causes included disruption of the external nasal valve, alar rim, and alterations to the nasal bones.4

Understanding the blood supply to the nasal tip is crucial when undertaking an open rhinoplasty, because inadvertent damage of the lateral nasal artery (e.g., during alar base resection) may lead to soft-tissue necrosis of the tip.1 The nose normally receives its blood supply from both the ophthalmic and facial arteries. The ophthalmic artery branches supply the cranial aspect, and the facial artery branches supply the caudal aspect. In most rhinoplasty, this vessel is divided, so the blood supply becomes dependent on a branch of the angular artery called the “lateral nasal artery,” which passes from the nasojugal groove over the alar.1,2

Sensory innervation of the external nose is from the trigeminal nerve (CN V) divisions I and II. The supraorbital and supratrochlear nerves from the ophthalmic division supply the cephalad portion, while the external nasal branch of anterior ethmoid supplies the middle vault and nasal tip. Following open rhinoplasty, patients typically experience reduced sensation to the nasal tip, but in most cases this fully recovers with time. Discussing this preoperatively is important so that they have some expectation of this.1–3

lateral cartilage and the nasal septum. The nose is considered to have two valves: internal and external. Both of these are important in relation to nasal airflow characteristics and problems with nasal obstruction. The external nasal valve is created primarily by the caudal edge of the lateral crus and nasal septum, with contributions from the ala and nasal sill soft tissues. External valve collapse may be seen with nostril collapse on inspiration. This can occur following surgery to the alar or refinement of the tip with alteration to the lower lateral cartilages. Cartilage grafts such as alar contour grafts, lateral crural strut grafts, or alar batten grafts can help address problems with the external nasal valve to reinforce the alar. Also correction of a deviated septum can be effective if this is the underlying cause. The internal nasal valve is the narrowest portion of the nasal airway and is therefore particularly important in regulating airflow resistance. It provides a significant amount of total airway resistance. It is formed by the junction of the caudal border of the upper lateral cartilages and the nasal septum where they form a T shape. A normal internal valve angle is 10 to 15 degrees and if this angle becomes more acute, obstruction is likely to occur. Where there is internal valve obstruction, cartilage spreader grafts may be placed between the upper lateral cartilages and the septum cranially to alleviate the problem. The turbinates are also relevant to airflow through the nose. They are paired bony structures that regulate and humidify inspired air. There are three turbinates each side: superior, middle, and inferior. The lateral crural complex is the term used to describe the lateral crus of the lower lateral cartilage and the accessory cartilage of the nose as a single entity.1–3

The scroll area is the region of abutment between the upper and lower lateral cartilages. The lateral crural complex is formed by the lateral crus and accessory cartilage (see Fig. 115.1). There is no named medial crural complex. The piriform aperture (derived from the Latin “piri,” meaning pear) is a pear-shaped opening of the skull where the nose is situated. The keystone area of the nose refers to the point at which the upper and middle vaults meet (see Fig. 115.1). It usually represents the widest part of the nose. The keystone area is one of the most challenging areas to refine well during rhinoplasty. It is frequently manipulated when undertaking component reduction and refinement of the dorsal hump. Given the three-dimensional structure of the keystone area and the fact that it represents an interface between nasal bone, upper lateral cartilage, and septum likely accounts for this.1,2 1028 Part VII ■ Aesthetic Surgery

Empty nose syndrome describes a situation in which a patient has nasal obstruction and a dry nose following nasal or sinus surgery.1 Most commonly, it occurs after resection of the inferior turbinate. Symptoms may be delayed for months or years after surgery and are counterintuitive, as there is no physical obstruction present. The turbinates are paired bony structures that regulate and humidify inspired air. The inferior turbinate is the primary turbinate treated in rhinoplasty, and a severely deviated septum may induce contralateral turbinate hypertrophy to balance bilateral nasal cavities. A hypertrophied turbinate may be responsible for up to two-thirds of airway resistance. The two most common approaches to surgical correction of turbinate hypertrophy are outfracture (using a Boise elevator or a Vienna speculum), or submucosal resection and removal of underlying anterior bone.

possibly biopsy. Gradual worsening of an airway obstruction, particularly in smokers or in association with epistaxis, may indicate a neoplasm and warrants further investigation. The nasal airway contributes around half of total nasal obstruction and can significantly reduce airflow when mucosal swelling is present, such as during a cold. During inspiration, the internal nasal valve narrows from negative pressure, but the nostrils usually open to facilitate airflow. Nasal obstruction can be either anatomic or physiologic; constant obstruction is more likely, but not exclusively, caused by a structural problem such as a deviated septum. These frequently require surgical intervention in the form of a septoplasty. Rhinitis medicamentosus is a condition arising secondary to excessive use of nasal congestants such as Afrin. Treatment involves stopping the offending agent (not continuing with it) and may include antihistamines and steroids.1–3

deformity? The cartilage spreader graft is placed between the septum and upper lateral cartilages near to the nasal bone to increase the distance between them and open the angle of the internal nasal valve. It can additionally be used to help straighten a deviated dorsal septum or smooth the dorsal aesthetic lines, as well as correct an open roof deformity. The radix graft involves placing a small piece of cartilage within a soft-tissue pocket over the proximal nasal bone. This can help mask deformity or bony deficiency in this region by augmenting the nasofrontal angle or redefining the radix further cephalad. This can provide the appearance of a lengthened nose. The alar spreader graft is placed between the lateral crura and vestibular skin to improve external nasal valve function and correct a pinched nasal tip deformity. The septal extension graft controls projection, rotation, and support of the nasal tip and helps create a supratip break. The alar rim graft is placed within the intranasal rim to correct notching and retraction (see Fig. 115.14–115.16, Essentials of Plastic Surgery, third edition).1–4

There are many different cartilage grafts used to improve the nasal tip appearance or projection.1 A columellar strut graft is commonly used in rhinoplasty. It involves placement of a strip of cartilage, most commonly harvested from the dorsal septum, vertically between the medial crura of the lower lateral cartilages. During an open rhinoplasty, it is normally fixed directly to the nasal spine or premaxilla and inserted into a tight soft-tissue pocket. It may also be secured with transfixion sutures through the caudal septum and lower lateral cartilages. It helps maintain or increase tip projection and aids in shaping the columellar–lobular angle, while providing structural support to the caudal part of the nose.2 The cap graft is placed between the tip-defining points and the medial crura. It serves to increase projection or refine the infratip lobule. Shield grafts are placed on the anterior middle crura and extend to the nasal tip to improve tip projection and definition. Not all grafts use solid pieces of cartilage. Instead, some use morselized cartilage by itself or mixed with a product such as a fibrin glue or placed within a soft-tissue pocket of fascia like a small pillow. One example of this is a soft triangle graft which involves placement of morselized cartilage graft adjacent to the infratip lobule and deep to the soft tissues. It is useful for closing dead space and supporting the soft triangles. The onlay tip graft is a piece of cartilage placed horizontally over the alar domes. The objective is to increase tip projection and definition and improve the contour of the infratip lobule.1–3

Rhinoplasty can be performed via open or closed (endonasal) approaches. The choice between the two will depend on many factors including surgeon’s and patient’s preferences and the elements of the nose, which require alteration. There continues to be debate at international conferences as to which is better and there will be some surgeons who only do open, some who only do closed, and others who will vary their approach according to patient factors. For example, some will do secondary or revision rhinoplasty open even when they do most primary rhinoplasties closed. Overall, there is no strong evidence to show one technique is better than another. The main advantage of using an open approach is that the underlying framework of the nose is exposed and is therefore easier to directly visualize and make incremental changes to it. In contrast, endonasal approaches can be more challenging to view the anatomy clearly. Open rhinoplasty facilitates alterations to the nasal tip, alae, dorsum, septum, nasal bone, and radix. However, it does leave a small but permanent scar within the columella. Provided this is closed with care and attention to detail, it becomes very difficult to see further down the line. Intraoperatively, the open approach frees up one of the surgeon’s hands, allows direct control of bleeding with electrocautery, and increases options for cartilage grafts. In contrast, closed approaches avoid the external scar, minimize postsurgical edema, allow visualization of the incremental changes to the underlying framework through an intact skin envelope, and may decrease surgical duration and recovery, although this is likely to be surgeon dependent.1,2 1030 Part VII ■ Aesthetic Surgery

Endonasal approaches to rhinoplasty require septal incisions in order to access the septum and lateral cartilages. They include complete and partial subtypes. During a complete (full) transfixion, the entire septum is incised at the membranous and caudal cartilaginous junction. This releases the tip completely and exposes the nasal spine and depressor septi muscle. It disrupts the attachments of the medial crural footplates to the caudal septum and can result in a loss of tip support and consequent loss of projection. In contrast, a partial transfixion begins caudal to the anterior septal angle and ends just short of the medial crural attachments to the caudal septum. A limited partial transfixion provides less tip access but allows preservation of attachments between the medial crural footplates and the caudal septum. A hemitransfixion approach is created unilaterally at the junction of the caudal septum and columella. A high septal transfixion does not violate the junction of the caudal septum and the medial crura or membranous septum.1,2

Rhinoplasty can be performed as an open or closed procedure. Both open and closed rhinoplasty approaches require internal nasal incisions. These are classified as those made through the alar mucosa and those made to the septum. Open rhinoplasty will also require an additional columellar incision but avoid the septal incision. Alar incisions are made between the upper and lower lateral cartilages (intercartilaginous), through the lower lateral cartilage (transcartilaginous/intracartilaginous), or below the lower lateral cartilage (infracartilaginous). This is sometimes called a marginal approach. There are advantages and disadvantages to each. For example, an intercartilaginous approach avoids incising through the cartilage and causing damage to it. A transcartilaginous approach can be useful when removing some of the lower lateral cartilages, as the cephalic trim can be incorporated into the incision. The infracartilaginous approach also avoids cartilage incision and consequent damage. There is a risk of causing notching, however, where the incision is placed too close to the nostril edge (see Fig. 115.5, Essentials of Plastic Surgery, third edition).1–3

Medial crural septal sutures are placed between the medial crura and the septum and are used for correction of a drooping tip or aging nose and help increase both tip projection and rotation. The “tripod” model is useful for understanding the relationship between nasal tip projection and rotation. When the lateral crura are shortened, the tip will be rotated, while projection is decreased. Shortening of the medial crura will derotate and deproject the tip (both options A and B will therefore derotate the tip). If equivalent portions of both medial and lateral crura are resected, the projection is decreased, while the rotation should remain the same (option D). Medial crural sutures differ from medial crural septal sutures. They involve horizontal mattress sutures placed between the medial crura that unify the lower lateral cartilages and stabilize the columellar strut to resist flaring of the medial crura.1–3

the septum. Dorsal hump reduction is probably the most common motivation for patients to undergo rhinoplasty. The dorsal hump usually comprises an excess of bone, soft tissue, and cartilage. It relates to the keystone area of the nose at the junction of the nasal bones, upper lateral cartilages, and septum. When performing a reduction, it is important to first separate out the anatomic structures so that each can be individually manipulated. This involves a subperichondrial dissection along the septum to separate the upper lateral cartilages from it all the way up to the nasal bones. Once free, assessment can be made of the excesses that need to be removed and incremental reduction can be performed primarily on the cartilaginous septum and the nasal bones. These are usually refined using blades, scissors, osteotomes, and rasps. Both palpation and visualization are undertaken throughout to ensure the desired reduction is achieved. It is common practice to perform the dorsal hump reduction early in the procedure and then make refinements to the nasal tip once this has been completed. In most cases, the upper lateral cartilages should not be reduced, as this risks leaving them short when reconstructing the nasal framework. This would otherwise contribute to the creation of an open roof deformity. In order to smooth the refined dorsum well, it may be necessary to implement other techniques including suturing the upper lateral cartilages to the septum, performing osteotomies, and placing spreader grafts. Spreader grafts are often used, not only to provide a satisfactory dorsal shape but also to ensure the internal nasal valves remain patent and avoid an inverted-V–shape deformity. The inverted-V deformity as viewed from the front is where an upside-down V-shaped indentation exists between the end of the nasal bones and the start of the upper lateral cartilages. In this situation, the cartilaginous area caudal to the nasal bones is noticeably thinner and indented compared with the width of the nasal bones. It is more likely to occur in patients with short nasal bones, but can occur where the nasal bones are long too. In a situation where an inverted-V deformity already exists, spreader graft placement between the septum and upper lateral cartilages is one of the main corrective approaches. These grafts may be harvested from the septum itself. Where there is a true excess of the upper lateral cartilages, some surgeons will flip the excess upper lateral cartilage between the septum to achieve the spreader effect.1–3

There are a number of options available for cartilage grafts in rhinoplasty. The most popular choice would usually be the septum itself, as cartilage can be harvested from this site without creating any functional deficit or a separate donor site.1 However, while septal cartilage may be plentiful in the primary rhinoplasty setting, where grafts are most often needed, i.e., in secondary rhinoplasty or nasal reconstruction, the nose may be cartilage 1032 Part VII ■ Aesthetic Surgery deficient and grafts will need to be harvested from elsewhere. Other options therefore include auricular2 and costal donor sites,3 using irradiated cadaveric cartilage4 or synthetic alternatives. Auricular cartilage is useful where curved contour grafts are required such as alar grafts in nasal reconstruction but is less useful where larger flat pieces are required, for example when septal extension grafts are needed. Auricular cartilage also lacks rigidity for structural support of the nose. Costal cartilage provides a useful supply but will lead to additional donor-site scars. Furthermore, it does have a propensity for warping and techniques have been described to limit this, including cross-sectional carving, placement of the concave side downward, and using percutaneous wires. Irradiated costal cartilage is another useful graft source, which avoids the need for a rib donor site and hence the skill set required to harvest this. Unfortunately, it too risks warping in the medium to longer term.4 Diced or morselized cartilage can be very useful for contouring the nose, particularly the dorsum when this has a deficiency perhaps following a poor primary rhinoplasty or in the setting of vasculitis and a saddle nose deformity.5,6 Synthetic implants remain a popular option for many surgeons. These include silicone, Gore-Tex, polyethylene, Dacron, and dermal substitutes.

Osteotomies are useful to allow repositioning of the nasal bones during rhinoplasty. Relative contraindications to their use include elderly patients with thin nasal bones, ethnic noses that are low and broad, and patients who wear heavy glasses. Osteotomies in rhinoplasty are described as either medial or lateral. They can be used independent of one another or may be combined. Lateral osteotomies are classified by the level at which they are performed in relation to the face of the maxilla (low to low, low to high, or double level). They are commonly used after dorsal hump reduction to correct an open-roof deformity or narrow a wide bony dorsum. Medial osteotomies are used to narrow the bony vault but may be used to widen it when combined with lateral osteotomies. Medial osteotomies should be performed before lateral osteotomies; otherwise, the bones will have little support, making them a moving target during the medial osteotomies.1–3

Flared alae are best corrected with partial-thickness wedge excisions that preserve the alar base and do not extend into the nasal vestibule. Alar base width reduction is also performed with wedge excisions, but in this case, full-thickness incisions are made. Alar base reduction will alter the alar–cheek junction and may alter the appearance of nasal projection. Medial crural suture placement is used to improve tip definition and provide tip support. Lateral crural strut grafts and alar contour grafts are used to treat alar rim deformities and provide internal alar support. Alar rim deformities are commonly due to excessive lateral crural resection during previous rhinoplasty.1,2

There are a number of structural factors that may lead to nasal obstruction, and management is specific to the cause. This patient displays a positive Cottle’s sign, in which lateral displacement of the cheek opens the internal nasal valve and improves airflow. The obstruction is usually caused by a decreased nasal valve angle (<15 degrees) or weak upper lateral cartilage where the septum and upper lateral cartilages meet. This is addressed by placing a cartilage graft between the upper lateral cartilages and the septum. Submucosal turbinate resection or outfracture (not infracture) may be helpful if the obstruction has resulted from turbinate hypertrophy. If the lateral nasal wall is weak, strengthening it with lateral grafts may be helpful. A septoplasty can also help correct nasal obstruction, depending on the cause.1–4

Rohrich et al1 proposed a treatment algorithm for managing patients with deviated noses (Fig. 115.2). Correction is performed through an open rhinoplasty technique and differs, depending on whether deviation is caudal or dorsal and whether the septum is C-shaped, S-shaped, or has a straight tilt. In the case of a straight tilt with the septum incorrectly located, the approach is to reduce the caudal septum onto the nasal spine, and this may require vertical sectioning to create a “swinging door.” If this is insufficient, small wedges of cartilage can also be excised from the convex side of the deviation, with cartilage scoring on the concave side to decrease the cartilage memory and straighten the septum. The caudal septum is sutured to the nasal spine and may be secured using a piece of septal cartilage. Cartilage scoring with batten grafts may be useful to treat C-shaped or S-shaped caudal deformity. Cartilage weakening and spreader grafts may be used to treat C-shaped or S-shaped dorsal deformity. Horizontal mattress sutures to the upper lateral cartilages may be used to control any residual deviation after correction with the other techniques. Osteotomies are generally used to correct a proximal (cranial) bony deviation.

deformity? This patient has an open-roof deformity of the nasal bridge following their previous rhinoplasty. The open-roof deformity occurs when a dorsal hump is reduced without bringing the nasal bones together in the midline. It may be conceptualized as shaving the top of a triangular prism structure and not folding the open edges back together again. The usual way to correct or prevent an open-roof deformity is to perform osteotomies and infracture of the nasal bones to bring them together and reconstruct the “roof.” It is possible to augment an open-roof deformity with a graft, but osteotomies are generally preferred, as they correct rather than mask the deformity. There are a number of techniques used to augment the nasal dorsum and these include septal, auricular, and costal cartilage grafts. Graft shapes include inverted-V, inverted-U, and A-shaped examples.1,2

A cephalic trim refers to removal of some of the lower lateral cartilages along their superior aspect. It may be beneficial in this patient in order to reduce the bulbous nasal tip and refine its appearance. It is also useful for increasing (not decreasing) tip rotation when this is required, but this was not a problem identified in this patient. Sometimes cephalic trims are further augmented with suture techniques in order to refine and support the nasal tip. A cephalic trim is unlikely to affect airway patency. Depending on the cause, patency may be improved with manipulation of the septum or nasal valves. Reduction of a dorsal hump removes the prominent nasal septum and nasal bones, as well as the upper lateral cartilages. It does not affect the lower lateral cartilages. Alar flaring is not usually affected by tip work and reduction of alar bases in this case would require a wedge excision.1–4