Special Considerations in Rhinoplasty Edward Buckingham M D

Special Considerations in Rhinoplasty Edward Buckingham, M. D. Karen Calhoun, M. D. Grand Rounds 12/20/00

Itroduction Alar base n Crooked/Twisted nose n Saddle nose n Non-Caucasian nose n Aging and rhinoplasty n

Alar Base Frontal, lateral, and basal views n Overall facial symmetry n

Alar Base Frontal View n n n Inner canthus Vertical 5 ths Horizontal 3 rds

Alar Base Lateral View n n Alar Facial Junction 2 -3 mm show

Alar Base Lateral View n n n Alar Facial Junction 2 -3 mm show Cephalic location

Alar Base Lateral View n n Alar Facial Junction 2 -3 mm show Cephalic location Alar hooding

Alar Base Basal View n n Isoscles triangle Columellar-lobule relationship 2: 1 Medal crural footplates 1: 1 Significant ethnic differences

Alar Base Ethnicity

Alar Modification Caucasian rhinoplasty n Black and Oriental n Indications n Alar flaring n Bulbosity n Excess width n Wide nostril floor n Imbalance after tip narrowing n

Alar Modification n n Conservatism Anatomic factors n n n Internal (medial) length External (lateral) length, shape, thickness, flare of alar margin Width, shape nostril floor/sill Shape of nostril aperture Length of lateral sidewalls of nose

Alar Modification Techniques General guidelines n n n Graduated fashion 1 -2 mm above alarfacial crease Precise repair, buried interrupted suture, 5 -0 mild catgut if needed

Alar modification n Decrease flare, elongate Decrease width Sill intact

Alar Reduction

Crooked Nose Difficult problem n Contributions n n n Septum, bony and cartilaginous dorsum, tip Manipulations must not compromise support

Crooked Nose

Crooked Nose n Lower 3 rd support mechanisms Structural integrity of lower lateral cartilages n Fibrous attachment cepahlic lateral crura and caudal upper lateral n Soft tissue attachment cephalic margin medial crura and caudal nasal septum n Interdomal ligament attachment to anterior septal angle n

Crooked Nose

Crooked Nose Diagnosis n n Facial symmetry Lower 2/3 deviation

Crooked Nose Diagnosis n n Facial symmetry Lower 2/3 deviation Palpation Tip recoil

Crooked Nose Correction n Pitfalls n n Deviations of the caudal, dorsal septum Irregularities upper lateral catilages

Crooked Nose Dorsum n n Hump removal Less from vertically oriented

Crooked Nose Dorsum n n Hump removal Less from vertically oriented Intermediate osteotomies Don’t elevate periosteum

Crooked Nose Lower 2/3 n n Free upper lats Prevent collapse n n n Mucosa intact Suture into position Open approach n Visualize deviated portions dorsal septum

Crooked Nose Lower 2/3 n Dorsal septal deviation

Crooked Nose Lower 2/3 n n Dorsal septal deviation Shave convex, unilateral spreader graft Further correction, on-lay grafts Airway Obstruction

Crooked Nose Lower 2/3 n n Ethmoid bone stenting Cartilage crosshatching

Crooked Nose Lower 2/3 n Caudal septal deviation

Crooked Nose Lower 2/3 n n n Caudal septal deviation Cartilage manipulation and suture Triangular wedge Replacement Columellar strut

Crooked Nose Post-op n n Abx for 7 days External cast 5 -7 days Suture removal 5 days Nasal bone massage

Saddle Nose n n Loss of profile, bony and cartilaginous dorsum Ethnic, trauma, infection, hematoma, overzealous profile reduction

Saddle Nose Repair Dorsal augmentation n Variety of techniques n Variety of materials n Septal, conchal cartilage n Autogenous cartilage, bone n Synthetic, alloplastic n Heterografts, homografts n

Saddle Nose Repair Resorption, Extrusion n Precisely sculpted, bevel edges n Careful preoperative diagnosis and planning n Constant supratip depression cartilaginous dorsum n Columellar retraction n

Saddle Nose Classifiction n Minimal Moderate tip-supratip differential n Mildly accentuated bony hump n Little columellar retraction n Overwide nose n Minimal supratip augmentation n Contouring hump n

Saddle Nose-Minimal

Saddle Nose Classification n Moderate n n Significant quadrangular cartilage dorsal height loss Significant collumellar retraction acute nasolabial angle Blunt trauma, bony pyramid broad and flattened Major n n All stigmata of moderate to greater degree Childhood or massive trauma, major nasal twist, septal deformity

Saddle Nose-Moderate

Saddle Nose-Major

Saddle Nose Correction Mark supratip depression n Anesthetic infiltration n Exacting pocket n Midline axial intercartilaginous stab n Blunt pocket dissection 1 -2 mm larger than grafts n Peroxide palpation n

Saddle Nose Correction Example

Non-Caucasian Nose Difficult n Strengthening weak cartilaginous structures n Preservation major support mechanisms n Careful S-STE manipulation n

Non-Caucasian Nose Characteristics Flat, broad, short n Infantile dorsum, lacking projection n Tip rounded poorly defined n Acute nasolabial angle n Thick, flaring, wide based alae, overhanging columella n Alar skin thick, fatty, inelastic, sebaceous glands n

Non-Caucasian Nose Characteristics Nostrils round, horizontally ovoid n Poorly defined nasofrontal angle n Anterior septal angle obtuse, cephalic n Pyriform aperature wide decreased bone to cartilage ratio n Nasal bones, domes more obtuse angle n

Non-Caucasian Nose

Non-Caucasian Nose Tardy

Non-Caucasian Nose Limiting Factors Thick, inelastic S-STE n Thick, short columella may preclude closure n Weak thin lateral crura, little support n Thin, small septum n Preserve ethnicity n

Non-Caucasian Nose n n n n n Many recommend open approach Strut graft, maybe doubled Most no rotation, no cephalic trim Transect domes, no resection, suture at more acute angle Dorsal grafting, narrowing Multi-layered tip grafts Excise fibro-fatty tissue Cartilage plumping grafts Alar reduction

Non-Caucasian Nose Postop 3 -4 weeks for 6 months n Kenalog 10 mg/d. L n

Aging and Rhinoplasty Special consideration n Young, purely cosmetic n 15 and 17 n Animal models n Conservative alar, septoplasty n

Aging and Rhinoplasty n Consultation Time and money n Self image n Changes of aging n Longstanding recent dissatisfaction n Undesired life change n Medical problems n

Aging and Rhinoplasty n n Tip support weakens Descent of nasal tip Nasal elongation Nasolabial angle changes

Aging and Rhinoplasty n Cadaveric studies Alar cartilage flattened, fragmented n Loss of upper lower attachments n Thin nasal bones n Skin thinner less elastic n n Skin heals less aggressive, finer scars

Aging and Rhinoplasty n n Changes in surrounding face Maintain tip support mechanisms n n n Columellar strut useful Care of septal mucosa Wide undermining of skin possibly Use of external incisions(dorsal) Fine 2 -3 mm osteotomes Extended taping

Aging and Rhinoplasty

Case

Case n Keys include correction of underlying septal deformities, release of the upper lateral cartilages with resuturing to prevent collapse, asymmetric hump removal.

Summary Challenging n Special consideration and technique n