External Rhinoplastyassesment and techniques

Presenter- Dr. Abhineet

Moderator- Dr. R.R. Barle

Indications-

Elaborate reduction & augmentation. Severe nasal trauma. Extensive revisions. Congenital deformities.

Pre op aesthetic assesment-

Standard 35 mm photographs taken in frontal, full lateral, basal and left & right three qtr. Lateral view as gold standard for pre op. evaluation.

5 mega pixel camera with independent flash lights.

Aesthetic terminology- Nasion-deepest point of NFA.

I. ideal location is set between lash and crease line of upper lid.

II. Nasion height is measured from vertical tangent to glabella.

Dorsum-( on anterior view.)

I. Intercanthal width(EN-EN)

II. Parallel dorsal lines

III.Base bony width(X-X)

IV.Tip defining points / philtrum.

V. Alar width(AC-AC)

VI.Alar flatre(AL-AL)

Cont.. On lateral view-

I. NFA -36* male/34* female measured from ideal nasion(Ni) to ideal tip(Ti).

II. Ni to Ti i.e. length of nose is 2/3rd of mid facial height.

III. Ti- ideal tip projection(AC-Ti) is 2/3rd of length of nose.

IV. Final aesthetic line- concave for female/ flat for male. If a hump is present, the line is drawn through it.

Radix And Dorsum Aesthetics

Dorsum And Tip Assesment

Tip aesthetic assesement- Intrinsic criterias- alar cartilage config’n.

I. Volume-size & shape of lateral crura.

II. Definition-convex domal & concave lateral crura.

III.Width-interdomal distance between Ti. additional criterias-abutting structures.

I. Projection-intinsic & extrinsic.

II. Rotation- tip angle-105* female/100*male.has inrinsic and extrinsic factors.

III.Position- location of tip along the dorsal line.

Base aesthetic assesment-

1. Columella base.

2. Pillar.

3. Infralobule triangle.

4. Soft triangle.

5. Lateral wall.

6. Alar base.

7. Nostrill base.

8. Nostril.

Cont.. Aesthetics of 4 components assesed-

I. Alar flare/width.

II. Columella.

III.CLA.

IV.Nostril.

ALWAYS

Make the tip fit the ideal dorsum

Operative sequence- General anaesthesia & local anaesthetic

injection Open approach incision Elevation of skin envelope. Septal exposure via transfixion incision. Creation of symmetrical alar rim strip. Incremental hump reduction. Caudal septum & ANS excision. Septoplasty. Osteotomies.

Graft preparation Spreader grafts Columellar strut & sutures Tip sutures Closure Alar base modification Alar rim support grafts Doyle splint & external & nasal block.

Transcollumellar

External approach Crosses collumella just above flared ends of

the medial crura If too close to the lip, “dip” deformity

– No cartilage support to counteract tension generated by the healing skin

Notching at the midline – “aggie mark”, Improved scar camouflage

Radix reduction- Intervening soft tissue excise under skin flap

at level of radix & glabella. Bony reduction-

I. Separate radix from bony dorsum by a line at level of lateral canthus.

II. Define ideal nasion/NFA/new dorsal line.

III.Dorsum is lowered 1st followed by radix up to NFsuture line.

NEVER try to do an en bloc reduction as you will remove too much dorsum & too little radix.

Radix augmentation-

As a balancing procedure to minimize hump reduction thus maintaining both dorsal height and more natural looking nose.

Use of fascia grafts/DC-F/DC+F grafts. Most pt. can accept under but not over

correction.

Dorsal reduction Incremental approach is followed. Bony rasping in subperiosteal tunnel is used in

midline & then progressively on sides. It continues till height of dorsum as it relates to nasion has been achieved.

Cartilaginous vault reduction by-

I. Split hump technique.

II. Transverse en bloc. Excision of septum lowers dorsal height while

that of ULC narrows width. Once osteotomies completed additional

rasping & excision may be needed.

Osteotomies- Lateral osreotomies- to achieve movement

of lateral wall to narrow bony width. It should go beneath the widest point of

base bony width.

I. Low to high

II. Low to low Routes may be intrasal, intraoral,and

percutaneous. Intraoral approach to be too low and

inflexible while percutaneous one leads to too many segmental bony bridges and mucosal perforations.

Medial oblique osteotomy- coupled with low to low ,to narrow broad bony dorsum.

Double level osteotomy- coupled with low to low, along inferior border of nasal bone and parallel to it. Goal is to reduce convexity of lateral wall.

Paramedian osteotomy-straight ones parallel to midline with out changing height.

Micro osteotomies- to correct intrinsic bone irregularities.

Spreader grafts An integral part of rhinoplasty both for

functional and aesthetic reasons.

They prevent internal nasal valve collapse & inverted v deformity of dorsum.

15-20mm long 3mm high, placed in extramucosal tunnel with cephalic portion under bony vault.

ULC,spreader graft & septum sutured together.

Dorsal augmentation Fascia graft-deep temporal fascia as single

or folded sheet is guided into pocket up to radix & sutured in supratip area to cartilaginous vault.

DC-F Grafts-diced cartilage placed in fascia pocket.

Rib grafts-usually 7th/ 9th rib crtilage.it provide excellent structural support with little risk of warping.

Septal cartilage- prone to visible edges under thin skin and difficult to obtain in secondary cases.

Biomaterials for augmentation.

Silicone rubber PTFE High density polyethylene Polyester and polyamide mesh Titanium Ceramic & non ceramic hydroxyapatite.

Nasal Tip Dome: formed by the junction of the medial

and lateral crura– Two point tip: aesthetically pleasing– Tent deformity: Single point tip

• Overtight suture or poorly placed tip graft

Sesamoid Cartilage– Accessory cartilage between lateral crura and

piriform aperture

Cephalic border of the lower lateral cartilage forms hinge with upper lateral cartilage

Tip shapes-

Broad tip Ball tip

Bulbous tip

Tip Support

Anderson: nasal tip similar to a Tripod– Conjoined medial crura and two lateral crura

represent the three legs of the tripod

Major support– Size, shape, resilience of medial and lateral crura– Fibrous attachment of the medial crura feet to the

caudal septum– Fibrous attachment of the caudal margin of the

ULC to the cephalic margin of the LLC

Tip Support

Minor Support– Ligamentous sling between the alar cartilages– Cartilaginous septal dorsum– Sesamoid complex – extending the support of the

lateral crura to the piriform aperture– Attachment of the alar cartilages to overlying skin

and musculature– Nasal spine– Membranous septum

Symmetrical rim strips-

Cephalic portion excised in all cases to reduce volume of tip,to increase malleability.

Lateral crura is not excised when major convcavities of lateral crura exist.

Actual excision begins at domal notch the progress laterally,preserving 6mm strip retaining sufficient to support nostril rim & preventing alar retraction.

Columellar strut & suture-

It serves three purpose: tip stability,tip projection & columellar shape.

It creates a unified tip complex and symmetry.

Create a true pocket between middle and medial drura while preserving intercrural fibrous connection.

Domal creation suture-

To create ideal aesthetic tip anatomy by creating a convex domal segment next to a concave lateral crura.

Too tight- sharp point under thin skin. Too loose- failure of tip definition. Too medial- snubs off tip . Too lateral- lengthen infralobule.

Interdomal suture-

Controls tip width. Too tight creates single pointed tip

while too loose causes a wide tip so keep in mind “ tip diamond” concept to preserve normal angle of domal divergence 30*

Domal equalization suture-

To insure symmetry of tip. It is probably the easiest to insert and

most difficult to do wrong.

Lateral crural mattress suture-

Widely used in treatment of wide/broad/ boxy/ ball tips.

It is a better alternative to segmental excisions that ultimately led to bossa formation or lat. Crura collapse.

A simple transverse mattress is placed at point of max. convexity on lateral crura.

Tip position suture-

Achieves tip rotation & tip projection to create “ supra tip break”.

It is not done till ideal intrisic tip has been achieved.

Most powerful of all tip sutures & must never be tied too tight …

No need to include columellar strut.

Add on grafts- Once suturing is complete ,to add

refinements as enhancement. Excised alar cartilage is preferred over

rigid septal / conchal cartilage . Accentuate dome defining points and tip

diamond feature. 5 types-

domal/shield/diamond/folded/combination.

Alar rim grafts- To correct alar rim retraction &depression as

subtle effect of tip suturing. Grafts 8-12 mm long 2-3 mm wide with

tapering cephalically both in width and thickness.

2 types- ARG -placed subcut.parallel to rim and 2-

3mm back. ARS- sutured to true marginal rim incision .it

is useful in ext. nasal valve collapse.

Base modifications(narrowing) Nostril sill excision-to reduce”nostril show”. It is a

vertical trapezoidal wedge excision.

Alar wedge excision- to reduce alarflare.it is an elliptical excision wit inferior border placed in alar crease, down to mid muscle level without penetrating vestibular skin.

Combined sill/base excision- to narrow alar base maximally while reducing alar flare at the same time.

Columellar Labial Angle--

Surgical modification consists of preservation,resection,augmentation of either the columellar/ANS.

Columella-Vast majority of the problems are due to caudal septal deviations that needs correction.

Most common is hanging columella due to prominent caudal septum that needs resecting lower half of caudal septum or straight excision of entire caudal septum to shorten nose.

Retraction of columella is corrected by long wide columellar strut.

ANS- if prominent either shortened or its underlying bony webb depened.

Retracted ANS can be isolated or part of hypoplastic maxilla. It needs a large columella strut and small cartilage graft placed subcutaneously in columella base.

Need of prepyriform augmentation in hypoplastic maxilla using diced cartilage or hydroxyapp. granules

Post op dressing-

Open verses Closed ???

Open– Much better exposure of structures– More accurate placement of grafts– More accurate structural diagnosis– Teaching value

Closed– Possibly faster than open– No external scar– Avoids tip edema– No loss of tip support

Complications

Hemorrhage Wound infection TSS Septal haematoma. Septal abscess. Septal perforation Nasal obstruction Nasal deformity.

Hemorrhage - Intraoperative bleeding- major bleed

follows medial osteotomies or turbinectomies.

Controlled by packing by epinephrine soaked gauze or cauterization.

Postop. Bleed can be well controlled with nasal tampoons.

Infection- Require aggressive treatment as I&D, gauze packing,

high dose broad spectrum i.v. antibiotics. TSS- symptoms

I. Fever/hypotension/ GI symptoms/errythematous

macular rash with desquamation.II. Admitted to hospital,nasal packs removed and

cleansed. scarring,skin necrosis,horrendous appearance are

complications. Avoided by at least 5 days of post op. period.

Septal complications- Septal hematomas- a unilateral inferior

incision with b/l silastic splints. Septal abscess- incision followed by

penrose drain sutured in place for 4 days, along with appropiate antibiotics.

Septal perforation- poor technique when perichondrium was removed with septum on one side / associated friable mucosa.

Nasal obstruction- In early period- mucosal oedema, nasal

crust formation.

I. Judicious use of nasal saline spray and nasal decongestant.

In late period- septal deviation,nasal valve narrowing, vestibular scarring,alar collapse, overcrowding of intranasal structures.

Nasal deformity-

Narrow dorsum. Saddle nose. Pollybeak tip/ pointed tip. Drooping of tip. Thick columella. Caudal septal deviation. Uneven dorsum with show of underlying graft

material.

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