.

March 7, 1998, Kyung Shik Suh, M.D

References

1. Tardy ME: Rhinoplasty in Otolaryngology- head and neck Surgery, Cumming et al. eds, 2nd Ed., 1993, St. Louis, Mosby, pp 807-856

2. Farrior RT and Farrier EH: Special Rhinoplasty Techniques in in Otolaryngology- head and neck Surgery, Cumming et al. eds, 2nd Ed., 1993, St. Louis, Mosby, pp 857-886

3. Toriumi DM: Open Rhinoplasty in Otolaryngology Head & Neck Surgery, Bailey et al. eds., 1st Ed., 1993, Philadelphia JB Lippincott, pp2128-2140

4. Johnson CM Jr and Toriumi DM, Open Structure Rhinoplasty, 1990, Philadelphia, WB Saunders

5. Anderson JA and Ries WR, Rhinoplasty: Emphasizing the External Approach, 1985, Stuttgart, Georg Thime Verlag

6. Nolst Trenite GJ: Trauma reduction in rhinoplastic surgery, 1991 Rhinology, 111-116

7. Esthetic Nasal Surgery, Manual for Rhinoplastic Dissection, 1996, Ghent, Department of ORL and Anatomy of the University of Ghent

Advntages of Delivery Technique

1. good visulaization
2. easy to operate
3. good for begginer and teaching

Disadvantages of Delivery Technique

1. greater exposure of the lower lateral cartilages
2. compromising the support mechanisms of the nose
3. intercartilaginous incision disrupts the major support mechanism
4. full-transfixion incision divides another major support mechanism

Terms

nostril base of the nose (subnasale) rhinion nasion pogonion menton=mentum philtrum glabella Frankfort horizontal trichion orbitale tragion columella/labial angle nasolabial anlge nasofrontal angle tip/supratip pronasale infratip lobule tip-defining points dome, interdomal ligament soft tissue triangle anterior septal angle posterior septal angle

	The Ideal Nose The facial thirds of Leonardo da Vinci = The width of nose at its base should be approximately the distance between the eyes(medial canthus). The length of upper lip is about twice that of lower lip and chin.
	Tip -Slight Upward Rotation : better Nasofacial angle = 36 degrees Nasofrontal angle = 120 degrees Nasomental angle = 130 degrees Mentocervical angle = 85 degrees

Types of incision

1. Marginal incision vs. Rim incision
2. Transcartilaginous incision
3. Intercartilaginous(Limen Vestibuli) incision
4. Transfixion incision
5. Transcollumelar incision
6. Lateral osteotomy incision
7. hanging columella deformity
8. buckling of columella

Anatomical and diagnostic considerations

Nasal Tip-Support Mechanisms

* Due to anatomical variability, a Minor tip-support mechanism may assume Major tip-support status

Vaculature

1. dorsal nasal a.
2. angular a.
3. lateral nasal a.
4. superior labial a. ---> columellar a.

Skin Flap - dissection through avascular plane: very important

Open Rhinoplasty

History

1. Rethi A. Operation to shorten an extremely long nose. Rev Chirugie Plastic 2:85, 1934

2. Padovan JF. External approach in rhinoplasty. Symp ORL, Aug 3-4:354-360, 1966

3. Goodman WS. External approach to rhinoplasty. J Otolaryngol 1973;2:207.

4. Anderson JR, Johnson CM, Adamson P. Open rhinoplasty: an assessment. Otolaryngol Head Neck Surg 1982;90:272.

5. Johnson CM Jr, Toriumi DM. Open structure rhinoplasty. Philadelphia: WB Saunders, 1990.

Indications for Open Rhinoplasty

External approach

The decision to use the open approach should be based on the magnitude of the deformity, the surgeon's experience and preference, and other factors.

Sturcture concept in rhinoplasty

• Today's patients want a natural, unoperated look.
• by creating favorable nasal tip projection and shape and by preserving a high or strong dorsal profile.
• The structure of the lower third of the nose is like a tripod mechanism, with the conjoined medial crura making up one leg and both lateral crura making up the other two legs
• Overresection of the lateral crura of the lower lateral cartilages - nasal bosses, alar retraction, nasal valve collapse, tip asymmetries, and overrotation of the lower third of the nose.

Anesthesia

1. local anesthesia with IV sedation
2. general endotracheal anesthesia

local anesthetic agents(total 2~2.5 mL)

• smallest volume, injecting it into the correct tissue plane
• lidocaine (1%) with 1:100,000 epinephrine
• 5-mL syringe and a 30-gauge needle
• injection sites

  1. columellar and marginal incision sites
  2. lateral dorsal walls
  3. osteotomy sites
  4. surface of the lateral crura
  5. nasal septum

• after each injection, the tissues are massaged, wait 10 to 15 minutes

Incisions

Incisions and dissections - the most important part of the procesure transcolumellar incision made at the level of the midcolumella midcolumellar incision could be placed in a higher-than-ideal position - particularly important in the nonCaucasian patient inverted-V midcolumellar incision angle of inverted V - 30 degree to prevent necrosis of the tip #11 blade - central part of the incision stabilizing the tip with the thumb and forefinger #15 blade - lateral extension of the columellar incision (very superficial) to prevent damage to the medial crura lateral extension of the columellar incision -angled slightly upward above a horizontal plane columellar incision is connected to the bilateral marginal incisions marginal incision should follow the caudal margin of the lateral crura (2 to 3 mm from the nostril margin) the nasal vibrissae run along the cephalic margin of the lateral crura and can act as a landmark for the placement of this incision

• @notching of the alar rim : if the marginal incision is made too close to the nostril rim, the incision may traverse the soft-tissue triangle just below the domes, and closure may result in aler rim notching
• angled Converse scissors can be used to elevate the columellar flap
• taking care not to damage the caudal margin of the medial crura
• columellar art.: two sizable vessels (the columellar branches of the superior labial artery) under columellar flap ---> bipolar electrocautery for hemostasis

Dissections

• dissection must be in a plane just above the perichondrium.
• if injured perichondrium & cartilage - repair with 6-0 chromic cat gut
• dissection proceeds toward the domes, a method of three-point countertraction
  • a sharp, wide double-prong retractor along the rim of the nostril
  • a sharp, narrow double-prong retractor on the intranasal side of the marginal extension of the columellar incision (medial crura)
  • a sharp, narrow double-prong retractor on the elevated columellar flap
• 2 types of flap elevation

1. elevation of flap from marginal incision then connecting columellar incision
2. direct flap elevation beginning with the columellar incision - greater control of the depth of the dissection

• superficial incision can be made along the midline and the perichondrium bluntly dissected laterally with a cotton-tipped applicator - showing cartilaginous dorsum and both upper lateral cartilages
• soft-tissue triangle - involed within the skin flap
• if bulky nasal tip soft tissue removal is needed, only remove fat tissue underneath the muscle layer

Surgery of the lower 1/3 of the nose

• cephalic trim - preserve at least 5 to 7 mm of intact lateral crural strip to maintain support
• for non-Caucasian nose, more cartilage should be left behind or a cephalic trim should be avoided
• delayed effects of scar contracture and redistribution of tissues
• overprojected nose, the surgeon may use a full-transfixion incision to divide the major support mechanism that attaches the cephalic margin of the medial crura to the caudal margin of the nasal septum
• septocolumellar suture can be used to reconstitute the divided major support mechanism and prevent further loss of tip projection in the postoperative period -
• (5-0 Prolene) through the medial crura and the caudal septum, fixing the nasal tip at the desired level - removed in 6 to 8 weeks, after sufficient healing has occurred
• The structure concept emphasizes this type of reconstitution of nasal support mechanisms whenever possible.
• interdomal ligament acts to support the nasal tip as a fibrous connection between both domes and the anterior septal angle.
• dome division - resuture
• interdomal ligament divided - interdomal mucosal apposition stitch, which involves passing a 4-0 chromic mattress suture through the mucosa inferior to the domal region and caudal to the anterior septal angle -no cartilage is incorporated in this stitch

Columellar strut

strut should measure 3 to 5 mm wide, 8 to 14 mm long and 1 to 3 mm thick precise pocket is created between the medial crura to a level 1 to 2 mm above the nasal spine strut is not resting on the nasal spine unless it can be fixed strut is sutured into position with a precisely placed 4-0 chromic mattress suture

• A columellar strut can be sutured in a pocket between the medial crura to increase tip support and preserve tip projection.
• no major and only one minor support mechanism of the nose has been disrupted -SSTE
• ---> a columellar strut can be sutured between the medial crura to help preserve projection and stabilize the lower third of the nose
• The strut is used to preserve tip projection, not necessarily to increase it.

Increasing nasal tip projection

1. tip grafting
2. lateral crural advancement
3. interdomal suture

sutured-in-place tip graft=shield graft

1. used to increase tip projection, increase tip support, improve tip definition, and preserve a bidomal tip configuration.
2. combined with a sutured-in-place columellar strut to increase tip projection and improve the contour of the lower third of the nose
3. tip graft is sutured to the caudal margin of the medial crura to provide a bidomal tip configuration and a solid structure that will resist the forces of scar contracture
4. shield-shaped tip graft is carved from autologous cartilage (septal, auricular, or costal cartilage), with the thickest portion of the graft at the leading edge (with one side perichodrium intact?)
5. Meticulous sculpting of grafts is especially important in patients with thin skin.
6. In patients with medium to thick skin, the tip graft can act as a rigidly supported structure producing an improved nasal tip contour.

Insertion of cartilage grafts

Indications for a sutured-in-place shield-shaped tip graft

nasal tips that are bulbous, underprojected, asymmetric, or poorly supported revision rhinoplasty major nasal reconstruction non-Caucasian rhinoplasty cleft-lip nose deformity.

• sutured into position to prevent migration in the postoperative period
• last step before flap closure : using bipolar electrocautery to stop any bleeding

Alar base wedge resection(Nasal base modifications)

• for narrowing the nasal base
• for decreasing the length of ala
• combined for increasing tip projection with columellar support
• for cleft lip nose

Auricular composite graft and island flap

• for graft harvesting

1. anterior approach - easier but visible scar
2. posterior approach - difficulty but acceptable scar

Approximation

edges of the incision approximated without tension interrupted 7-0 nylon sutures can be used to close the cutaneous portion of the columellar incision nylon suture in the midline interrupted 6-0 chromic sutures to close the lateral (intranasal) portion of the columellar incision chromic suture at the junction of the vertical and horizontal segments of the columellar incision two 5-0 chromic sutures to close each marginal incision small piece of Surgicel can be placed intranasally just below the domes

Postoperative care

Complications Open Rhinoplasty

Minor long-term complication

1. Nasal tip drooping
2. Rocker formation
3. Polly-beak deformity

Surgery of the middle and upper 1/3 of the nose

Hump resection

1. for excessive nasal hump removal
2. for medial osteotomy

Osteotomies

1. lateral osteotomy
2. medial osteotomy
3. intermediate osteotomy
4. Percutaneous lateral osteotomies - 2mm micro-osteotome

Dorsal graft

for covering the dorsal defect/nasal profile