Chapter 73: Rhinoplasty
Alexander L. Ramirez, MD & Corey S. Maas, MD
The nasal skeleton may be divided into thirds (Figure 73–1): (1) the upper compartment (bony vault), (2) the middle compartment (upper cartilaginous vault), and (3) the lower compartment(lower cartilaginous vault). The upper third is bone, while the lower two-thirds are cartilage.
The bony vault is made of the nasal bones and the nasal processes of the maxilla. They join to form a convex bony arch that provides stability to the nose. The nasal bones are widest at the nasofrontal suture, become narrowest at the nasofrontal groove, and then become wide again at the rhinion. The dorsal border of the septum fuses with the caudal end of the nasal bones so that the septum acts like a rigid and fixed beam on which the cartilaginous structures are suspended.
The nasion refers to the nasofrontal suture, where the nasal bones fuse with the frontal process. The rhinion is where the caudal border of the nasal bones meets the upper lateral cartilages. The upper lateral cartilages are not only juxtaposed to the nasal bones here, but there is actual overlap among them. This area is referred to as the “keystone” or “K” area. There is up to 11 mm of overlap in the midline.
Unlike the nasion and rhinion, which correspond to exact anatomic landmarks, the radix or the root of the nose refers to a general location. On frontal view, the radix is formed as the space between two gently curving continuous lines from the superior orbital rims to the lateral nasal walls (Figure 73–2). On profile, it is the lowest portion of the nasal dorsum, correlating to the nasofrontal groove or angle (Figure 73–3).
Upper Cartilaginous Vault
The upper cartilaginous vault is comprised of the upper lateral cartilages. The cephalic border is relatively immobile because of the fusion of the upper lateral cartilages to the fixed quadrangular cartilage of the septum and the overlap with bone at the keystone area. Laterally, the upper lateral cartilages are fused to the pyriform aperture by dense fibroareolar tissue and are attached to the alar cartilages caudally. The caudal edge of the upper lateral cartilage curves in the same direction as the overlapping cephalic edge of the alar cartilage, creating the scroll. In many ways, the bony pyramid and the upper lateral cartilage act as a single osseocartilaginous unit.
In contrast, the caudal border of the upper lateral cartilage is mobile. The thickened caudal border of the upper lateral cartilage acts as the internal nasal valve and moves with the respiratory cycle in a paradoxical fashion. With inspiration, the respiratory muscles create negative pressure within the entire upper respiratory tract. This causes the internal nasal valve to narrow. This increases air resistance and modifies currents to maximize exposure to nasal mucosa. At the same time in the lower cartilaginous vault, the nostrils flare, increasing the diameter of the external nasal valve.
Lower Cartilaginous Vault
The lower lateral cartilages or alar cartilages are responsible for the support and configuration of lower third of the nose. The lower third is mobile and animate. The alar cartilages are almost free-floating, only loosely connected by fibroareolar and muscular attachments to the septum. They are connected laterally to the sesamoid (accessory) cartilages, the pyriform aperture, and to the upper lateral cartilages. The alar cartilages are divided into three continuous segments called crura (Figure 73–4).
The medial crura form the shape of the columella and the nostril medially. They run along the caudal septum to the apex of the nostril and diverge anteriorly. The most posterior portion, called the medial crural footplates, extends toward but not to the nasal spine. They are short, face outward, and flare variably laterally. They do, however, tightly sandwich the caudal septum, a relationship that is important for tip support.
The intermediate or middle crura are the bridge between the medial and lateral crura. The point at which the medial crura diverge is most commonly considered the start of the intermediate crura. This bend in the alar cartilage is called the point of divergence or the medial genu. The angle created between the intermediate crura is defined as the angle of divergence and typically measures 50° to 60°. Angles greater than this tend to create a boxy or bifid nasal tip.
The apex of the alar cartilages is called the dome, lateral genu, or tip-defining point. This is the area where the intermediate crura merge with the lateral crura. The domes are connected to the anterior septal angle by dense connective tissue called the interdomal ligament. The lateral crura then extend laterally but do not parallel the entire rim of the nostril. Initially, the lateral crura follow the curvature of the nostril to the apex of the nostril opening, but then they turn obliquely superior and laterally to the pyriform aperture. While paralleling the alar margins, the lateral crura are outwardly convex, but as they curve superiorly, they flatten. It is the soft tissue of the lobules that create the shape of the nostrils—not the alar cartilages.
The three major factors in nasal tip support all relate to the alar cartilages. They include (1) the integrity and strength of the alar cartilage itself, (2) its attachment to the caudal septum, and (3) its attachment to the upper lateral cartilage. Overzealous resection of alar cartilage can lead to many pitfalls, including the loss of tip support, vestibular stenosis, or alar retraction secondary to scar contracture. The lower third of the nose is also called the tip-lobule complex or the base of the nose.
The concept of facial aesthetics and beauty is highly subjective. However, an understanding of aesthetic facial proportions serves as a guide when evaluating patients. It helps with interpreting surgical goals and concerns and it improves the surgeon’s ability to correct deformities. These evaluative aspects are not consistent for all patients, but are an approximation of ideals.
In the frontal view, the face may be divided into thirds, using the glabella and the base of the alae as points of divisions (see Figure 73–2). The base of the nose should be equal in width to the intercanthal distance. In the basal view, the alar base should approximate an isosceles triangle (see Figure 73–4). The distance from the base of the ala to the apex of the nostril should be two thirds of the distance from the base of the ala to the tip of the nose. The beginning of the flare of the medial crural footplates should divide the alar bases into equal halves.
In the profile view, the length of the nose is defined as the point from the radix to the tip (see Figure 73–3). It should be approximately two-thirds of the midfacial height. An aesthetically pleasing profile has two breaks or bends in the lines that make up the silhouette. First, immediately above the tip, there should be a mild depression called the supratip break. Below the tip, there is another bend called the infratip break or the columellar double break. This break marks the junction between the medial crura and the intermediate crura.
The nasal-tip projection is measured from the alar facial groove to the tip. It is appropriate at 50–60% of the nasal length. If it is greater than this value, then the nose is overprojected. If it is less than this value, then it is underprojected. These estimations are helpful in the clinical setting because one can easily be fooled by a cursory examination of the face. A nose may appear overprojected when the chin is retrognathic or it may appear underprojected when there is a large dorsal hump. On profile, the columella should parallel the long axis of the nostril; the nasolabial angle should be 90–95° in men and 90–110° in women. If the angle is greater than expected, then the tip is overrotated or vice versa.
Photographs are analogous to the audiogram in otology—they provide essential information that improves the evaluation, diagnosis, and surgical planning. The basic principles of photography apply. All photographs should be performed in a standardized format because it allows for comparison. Photographs should be taken with a solid background, such as medium blue, because this provides contrast but does not obscure facial features. It is important to take pictures at the subject’s eye level and to keep the Frankfort horizontal line parallel to the ground. The Frankfort line is an imaginary line from the top of the tragus to the infraorbital rim.
Four views should be obtained because each allows a unique analysis. (1) The frontal view is useful to evaluate the root and base of the nose for any deviations, asymmetries, and curvatures. (2) Bilateral three-quarter views are useful to analyze the alar cartilages and the tip-lobule complex. (3) Bilateral lateral views allow for the evaluation of tip projection and rotation, the length of the nose, and the symmetry of the nostrils and columella. In addition, any disruption of the silhouette of the nose, such as dorsal humps or the absence of supra- or infratip breaks, can be evaluated. (4) Finally, a basal view allows for an evaluation of columellar length, deviations, and asymmetries.
The choice for general anesthesia versus local anesthesia with monitored anesthesia care is largely a decision based on a discussion with patient, the surgeon’s personal experience, and the anesthesia staff. Regardless of choice, local anesthesia should be administered to improve surgical hemostasis, to aid in patient analgesia, and to aid in atraumatic dissection by infiltration into favorable and appropriate tissue planes. The injection should be in the supraperichondrial or subcutaneous musculoaponeurotic plane because this aids in evaluating the skin-soft tissue envelope in the appropriate plane. Overzealous injection should be avoided because this leads to a distortion of anatomy.
Anesthesia for rhinoplasty begins preoperatively. The patient should be treated with topical phenylephrine (eg, Neo-Synephrine) or oxymetazoline at least 15 minutes prior to surgery in order to begin nasal vasoconstriction. Once in the operating room and under sufficient anesthesia, 4% cocaine may be placed on cotton pledgets in the nasal vaults. Studies have shown that cocaine application for up to 20 minutes was without major complications, but that absorption is high. Therefore, cocaine should only be used after the application of a topical vasoconstrictor, which limits the absorption and the time of exposure to 10–20 minutes.
A 1:100,000 mixture of 1% lidocaine with epinephrine is then injected using a control syringe with a 1.5-inch 27-gauge needle. Each side of the nasal septum is injected, beginning posteriorly and inferiorly. These injections blanch and elevate the mucoperichondrium. Next, the lateral nasal walls should be injected via an intercartilaginous approach, staying close to the nasal bones and injecting as the needle is withdrawn. There is essentially no injection along the dorsum.
The pyriform aperture and the infraorbital foramen are infiltrated. The needle is then inserted through the vestibule toward the alar-facial groove to inject the angular artery. An injection is also placed at the base of the columella toward the nasal spine to control the columellar branch of the facial artery. The tip is finally injected via the vestibule, anterior to the alar cartilage and into the dome, with placement confirmed by blanching. Typically, only 10 cc of a local anesthetic is necessary to inject these sites.
The decision to proceed with an external (open) or endonasal (closed) approach is based on the surgeon’s preference and experience.
The endonasal or closed approach includes multiple routes of access (Figure 73–5). The cartilage-delivery method is an example of a closed approach that combines multiple endonasal incisions. In this approach, intercartilaginous incisions are combined with marginal incisions in order to allow for either externalization or delivery of the lateral crura. This allows for an enhanced visualization of the cartilage, an improved ability to manipulate the domes under direct vision, and better postoperative symmetry. The endonasal approach is used primarily when nasal tip morphology is normal. The major benefit is less dissection, leading to faster healing.
The external or open approach involves bilateral marginal incisions that are connected in the midline by a transcolumellar skin incision, usually in the shape of an inverted “V.” The main difference between an open and closed approach is that the open approach allows exposure of the tip-lobule complex without disturbing intercrural or alar-septal attachments. It also allows for better binocular visualization, both for teaching and studying deformed anatomy. In addition, the open approach allows for a more precise control of bleeding by electrocautery and a more precise correction of deformities. The disadvantage is the skin incision on the columella and the degloving of the nose, which adds operative time, requires a longer healing time, and is associated with more postoperative edema. In addition, studies indicate that the open approach is associated with a greater loss of tip projection than the closed approach.
The composition of the skin-soft tissue envelope is a critical component of understanding the lower one third of the nose. If this layer is thick and sebaceous, it lacks the ability to drape softly over the nasal skeleton. It creates tip definition because of the inherent memory or integrity of skin-soft tissue envelope itself and not from the cartilage. Thick skin may also overburden weakened cartilage, leading to collapse. In contrast, thin skin allows the impressions of the underlying structures to be more prominent. Alteration and molding of the alar cartilage must be done with precision in order to avoid visible deformities. The combination of a well-structured and stable nasal skeleton with a conforming skin-soft tissue envelope produces an aesthetically pleasing tip-lobule complex.
A useful metaphor to understand the dynamics of the lower third of the nose is to think of the alar cartilages as a tripod (Figure 73–6). The medial crura form one “leg” and the lateral crura form the other two “legs.” The modification of any leg will lead to tip rotation. For example, if the conjoined medial crura lose support or are shortened, the tip rotates inferiorly, resulting in an underrotated tip. The resection of one lateral crus leads to nasal-tip deviation toward that side. It is important to note that the shape of a weakened alar cartilage may also be modified by the contraction of scar tissue during the healing process. Overresection must be avoided to maintain stable alar cartilages, which allows for an accurate prediction of the surgical outcome.
A poorly defined and underprojected tip is well addressed with rhinoplasty. A columellar strut is often used, especially when using the open approach. Made from septal cartilage, it adds stability to the medial crura, allows for enhanced tip definition and projection, and prevents tip ptosis. The strut is placed in a pocket between the medial crura and extends just beyond the medial crura footplate. It should not rest on the nasal spine because this may cause clicking if it moves over the bone. In addition, tip grafts or dome-binding sutures may be used to improve tip projection and definition.
A bulbous tip is another common problem. It is caused by convex, long, and poorly defined lateral crura that are rounded because of an obtuse angle at the dome. To address this, cephalic trim is used to reduce the curvature of the lateral crura and to create a flat profile. At least 7 mm of remaining crura are needed to assure sufficient stability and strength. The excision of a triangle of cartilage just lateral to the domes is then used to reduce rounding from the obtuse angle. Staying lateral to the apex of the dome maintains the defining point of an unchanged tip and the resection of a superior-based triangle allows cephalic rotation and narrowing of the dome. Suture reconstitution of the lateral crura is important because it maintains the strength of the nasal skeleton.
The most common cause of acquired incompetence of the internal or external nasal valves is rhinoplasty. Internal valvular incompetence is seen when the angle between the caudal edge of the upper lateral cartilage and the septum is less than the norm of 15°. A spreader graft, placed between the dorsal septum and the upper lateral cartilage, is used to widen the angle and improve problems with the internal nasal valve. External valve incompetence is caused by excessive resection and weakening of the lateral crura of the alar cartilage, leading to instability. Repair is most commonly by placement of either a lateral graft that spans the crura or a batten graft to strengthen the cartilage and prevent collapse.
Skin thickness changes along the length of the nasal dorsum. It is thick over the nasion, thinnest at the rhinion, and thick again in the supratip area. This is essential to note because a straight dorsal profile of the bone and cartilage would not lead to an aesthetic profile; instead, it would lead to a concavity along the dorsum where the skin is thin. Therefore, it is important to preserve a slight convexity near the rhinion to account for the anatomy of the skin-soft tissue envelope.
Dorsal humps are usually more cartilaginous than bony in origin. They may be removed sharply or by rasping and often are combined with lateral osteotomies to prevent an open roof deformity (Figure 73–7). Hump removal is only successful if soft tissue, cartilage, or bone has been removed sufficiently to allow the lateral walls to fall medially to close the roof. Two errors leading to a flat dorsum despite osteotomies are uncorrected high septal deformities and insufficient resection in the keystone area of the upper lateral cartilages.
Lateral osteotomies are typically done intranasally, using a stab incision above the inferior turbinate to gain access to the pyriform aperture. The lateral osteotomy is started 1–2 mm above the base of the pyriform aperture and then follows a low to high trajectory along the nasal sidewalls. If the osteotomy is started at the base of the pyriform aperture, this segment of bone, along with the anterior portion of the inferior turbinate, may displace medially and partially block the airway.
The osteotomy cut is kept low, as close to the face as possible, to prevent any palpable step-off along the nasal wall and a “pinched-nose” appearance. At the cranial end of the nasal bone, from the osteotomy line to the dorsum, the back-fracture is usually performed digitally or occurs spontaneously with medial rotation and pressure of the osteotome (see Figure 73–7). The back-fracture is usually at the nasofrontal groove, the thin portion of the nasal bone. If the osteotomy enters the thicker bone of the nasofrontal angle a rocker deformity may result. In this situation, manual medial pressure to realign the displaced cephalic thick bone would cause lateral displacement of the caudal bone.
Medial and lateral osteotomies are used to completely mobilize the bony skeleton to change its position, width, and appearance. A medial osteotomy may be done through the incision used for either a closed or open rhinoplasty. Osteotomies are associated with extensive swelling and bleeding. They are typically not carried out until all the soft-tissue work of the lower two thirds of the nose has been completed.
The surgical dressing is applied immediately after osteotomies to minimize edema. If there is significant bleeding, small precut strips of telfa packing (a smooth-surfaced, absorbent material) may be placed. A thin coat of benzoin is applied over the nose and precut Steri-strips are applied cautiously over the nose from the root to the supratip area with 1–2 mm of overlap. If tip work has been performed, a sling around the columella is placed lightly enough for support, yet sufficient for adequate venous drainage of the tip. A plaster (eg, Thermacast) is applied in the usual fashion. Care must be taken not to be overvigorous with the dressing because it may disrupt the work already completed.
Patients require reassurance and instruction after rhinoplasty. They should be given a week’s dose of postoperative antibiotics and should be instructed to apply ice to their cheeks for 48 hours. Patients should refrain from heavy lifting, strenuous activity, excessive nose blowing, and wearing glasses for 4–6 weeks. Sneezing should be performed with an open mouth. In addition, patients should refrain from smoking and taking aspirin or ibuprofen for at least 2 weeks. Finally, nasal saline irrigation and half-strength hydrogen peroxide on a cotton applicator should be used to minimize crusting in the nasal passage and around the vestibule.
Complications after rhinoplasty are unusual; however, they require immediate recognition and treatment when present. As a result, patients are seen 1, 3, and 7 days postoperatively. The most common complications include infection, epistaxis, and skin loss. The risk of infection is usually minimized by the use of pre- and postoperative antibiotics. Epistaxis can usually be avoided by using a precise surgical technique; however, mild bleeding may be addressed with head elevation, ice packs, and gentle pressure. Heavier bleeding may require packing. There is always the risk of infection, despite the nose being a highly vascular organ. This is particularly true in revision surgeries or with high-risk patients who have diabetes, severe atherosclerosis, and who smoke. Conservative treatment with removal of the dressing, application of an antibiotic ointment, and local debridement is usually all that is needed to manage most cases.
The physician must always keep in mind that there are potential complications that may be related directly to the surgery. These include problems that have previously been discussed, such as open roof deformity, internal and external valve dysfunction, weakened alar cartilage, rocker deformity, a “pinched-nose” deformity, and vestibular stenosis. In all cases, patients should be followed closely and examined critically to identify problems and evaluate the surgical outcome.
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Figure 73–3. Nasal profile.
Figure 73–1. Nasal skeleton.
Figure 73–2. Facial proportions (frontal view).
Figure 73–4. Nasal base and alar cartilages.
Figure 73–5. Incisions for endonasal approaches.
Figure 73–6. Alar “tripod.”
Figure 73–7. Dorsal hump and osteotomy.