----------------------------------------------------------------------------- TITLE: CORRECTION OF THE CROOKED NOSE SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: January 22, 1992 RESIDENT PHYSICIAN: Bruce A. Scott, M.D. FACULTY: Karen H. Calhoun, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. ------------------------------------------------------------------------------ "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." I. Anatomy A. Skin and subcutaneous tissue - Thick vs. thin 1. Thickness varies throughout the course of the nose - Supra Tip: Thickest - Nasion: Thin - Tip: Thinner - Rhinion: Thinnest 2. Thick skin hides imperfections and subtle changes. Better result possible with thin skin but also less margin of error. 3. Must vary the deep support accordingly for good result. i.e. Rhinion (thin) should be left higher than adjacant area of lateral cartilage (thick subcutaneous tissue). B. Muscles 1. Depressor Septi - Origin: Incisive fosse of maxilla - Insertion: Caudal septum a. Only muscle whose function makes a change in nasal appearance b. Action on the feet of the mesial crura => tip drops with contraction 2. Procerus - Origin: Glabella - Insertion: Upper lateral cartilage - Can contribute to nasofrontal angle 3. Transverse Nasalis - Covering across mid nose 4. Nasalis - Alar 5. Nasalis 6. Levator labii superioris 7. Corrugator C. Septum - Dorsal and caudal borders provide support for nose, should be left undisturbed 1. Framework - bony and cartilaginous components a. Bony - ethmoidal plate and vomor b. Quadrilateral plate - cartilage 2. Periosteum of bony and pericondrium of cartilage are continous (easliy elevated together). Periosteum of bony spine, crests and vomer not continuous with pericondrium (sharp dissection necessary) D. Tip 1. Lower cartilages (paired) a. Divided in medial and lateral crura i. Medial - held together by ligamentous tissue in columella ii. Lateral - flare posterior superiorly away from nasal rim b. Dome - junction of medial and lateral crura. - Two point tip - aesthetically pleasing - Tent deformity - single tip point secondary to overtight suture, tip graft poorly placed c. Sesmoid Cartilage - Accessory cartilage between lateral crura and pyriform aperture d. Cephalic border forms hinge with upper lateral cartilage - important relation in rhinoplasty e. Tip Support i. Tripod - paired medial crura and post-superiorly flared lateral crura ii. Other Support - Ligamentous attachment of medial crural feet to caudal septum - Ligamentous attachment of lateral crura to pyriform - Ligamentous attachment of upper and lower cartilages - Ligamentous attachment between medial crura - Skin and mucosa - Caudal septum * Support weakens with age E. Mid Nose 1. Upper lateral cartilages (paired) - Triangular with base at septum and apex at pyriform - Upper portion under nasal bones approximately 1 cm, held by ligamentous fibers - Attach medially to septum 2. Septum broadens to form platform 3. Intranasal Valve - Junction of caudal upper lateral cartilage with septum - Ligaments laterally connect to pyriform to hold valve open (may be damaged by rhinoplasty, resulting in nasal obstruction) 4. Support - Septal platform - ligamentous connection - Lateral ligaments 5. Polly beak - Mid nose septum and upper lateral cartilages too anterior relative to dome - Inadequate cartilage removal in mid nose or too much tip drop F. Bony Vault 1. Paired nasal bones a. Midline suture b. Curved gradually - If too acute may cause overbroad nose, and might need intermediate osteotomies to correct c. Thick and strong at superior root - don't need to extend osteotomy this far 2. Frontal process of maxilla - Thicker than above - Osteotomes must extend into frontal process to narrow nose 3. Nasal spine of frontal bone - Medial support - Thick and strong II. Nasal Aesthetics and Analysis - Societal view of what is "aesthetic" or desirable A. Lateral View 1. Nasofrontal angle a. Deepest point level with upper edge of iris, supratarsal crease b. Angle approximately 120 degrees 2. Tip projection a. Many means to assess b. Columella to vermillion : base/tip = 1:1 c. 25% NF angle to chin, perpendicular line to tip-defining point d. 55-60% NF angle to alar crease, perpendicular line to tip-defining point (Goode method) e. 28% NF angle to vermillion/cutaneous border, perpendicular line to tip- defining point - Highest correlation with subjective analysis - Least interobserver variability (Crumley and Lanser 1988) 3. Tip rotation a. 90 - 100 in men b. 95 - 110 in women c. Assume normal upper lip 4. Dorsal contour a. Should be straight, strong b. Slight supratip dip 5. Columellar show a. 2-4 mm of show b. "Double break" B. Frontal View 1. Symmetry a. Deviation b. Depression 2. Dorsal width - Base of bony pyramid broader than intercanthal distance 3. Alar width a. Intercanthal distance b. Consider narrowing if 2mm greater 4. Alar height C. Basal View 1. Tip projection a. 2/3 columella b. 1/3 lobule c. Equilateral triangle 2. Nostril size and shape a. No boxy tip b. Pear shaped, symmetry c. 1/5 basal width each 3. Columellar width a. 1/5 base b. Rim, lobule and columella should be 1/5 4. Alar lobule width 5. Tip width and shape III. Pre-op Evaluation A. Patient selection and psychological factors 1. Majority of patients are satisfied with results of cosmetic surgery and most post-op dissatisfactions are transient - (Reich) 2.7% dissatisfied after 6 months, 750 patients 2. Prevention is best means of treating the dissatisfied patient a. Generally agreed that the more marked the deformity, the more likely the patient is to be satisfied with the result - Converse not true (i.e. patients with "minor" defects often quite pleased) - Surgeon's satisfaction does not equal patient's satisfaction b. Identify poor risk patients (Likely to be dissatisfied) - The patient who does not "hear" - Patients that make you intuitively uncomfortable - Patients who are psychotic, depressed or have personality disorders (consider psychiatric consultation) 3. Causes of dissatisfaction a. Physical complication or disappointment with anatomical change - No matter how well counseled, cosmetic patients pay little attention to the possibility of complications b. An unrealistic expectation - Don't oversell c. Lack of understanding or rapport between the surgeon and the patient 4. Management of the dissatisfied patient a. Listen attentively - Handle emotionality of dissatisfaction before factual discussion - Patients want respect and help not retaliation (i.e. litigation) b. Secondary procedure with same enthusiasm as initial procedure c. Return visits - don't abandon them - Titus Harris - "It is amazing how many patients get well on their own if we just let them." B. Examination 1. Facial asymmetry and overall facial appearance - Good and bad features - Personal habitus, dress 2. External nose - palpation and inspection - Thick vs. thin skin, skin quality - Lesions and scars - Evidence of trauma - Tip support 3. Intranasal exam - Septal deformity - Scars - Nasal airway - Nasal valve - Turbinates C. General medical history and physical 1. Hypertension (caution with epi) 2. TCA (caution with epi) 3. Anesthetic history - Previous local sedation - reaction, experience - Allergies (rare) 4. Bleeding - Personal and family history - ASA, NSAID - PT, PTT (Probably unnecessary) * 2-5% of patients may bleed despite above being normal D. Discussion of Patient's desires, surgical goals, and realistic expectations - Informed consent IV. Basic Technique A. Anesthesia 1. General vs. local Local cheaper, faster, safer 2. Monitors EKG, pulse oxymeter 3. IV line 4. Resusitation equipment 5. Blocks Glabellar, infraorbital nerve, inferior turb. 6. Intravenous agent Sedation, amnesia, analgesia Fentonyl (0.05 - 0.10 mg) SIVP Lorazepan (2-3 mg) 15-20 mins. pre-op Valium (2.5 mg ) Demerol B. Incisions 1. Transfixion and hemitransfixion a. Provides acess to the caudal septum medial crura and nasal spine. This is usually the first incision made during an endonasal rhinoplasty. b. It begins at the junction of the septal mucosa and lateral nasal mucosa, just caudal to the caudal end of the septum. It then angles downward, following the cephalic margins of the medial crura (not the caudal septum), and extends almost to the flared ends of the medial crura. It can be extended onto the nasal floor if access is required for increasing tip projection. c. Hemitransfixion incision is making this incision on one side only. Advantage is eliminating one incision, disadvantages are poorer access to the opposite septum, and possible distortion (creation of asymmetry) as the assymmetric incision heals. 2. Intercartilaginous a. Provides access to tip and midnose b. These incisions are made intranasally between the upper and lower lateral cartilages (within the limen vestibula or nasal valve area). They begin medially as an extension of the transfixion incision, and continue laterally the entire length of the lower lateral cartilages. It is important not to inadvertently cut through the lateral end of the lower lateral cartilage 3. Intracartilaginous a. Access to tip and midnose b. These incisions may be made through the vestibular mucosa only or through both vestibular mucosa and lower lateral cartilage. They, like the intercartilaginous, begin medially at the transfixion incision, and extend laterally, parallel to the caudal border to the lower lateral cartilage, extending to the lateral end of the lower lateral cartilage. They are usually 3-5 mm caudal to the cephalic end of the lower lateral cartilages, depending on the amount to cartilage to be removed c. Advantage of intracartilaginous incisions over intercartilaginous is that they are made caudal to the nasal valve area, thus lessening the chances of scar contracture of the nasal valve area with its attendent nasal obstruction 4. Rim or Marginal a. Incisions parallel the caudal borders of the lower lateral cartilages - Landmark: cephalic border of nasal vibrissae b. They are always used in an open or external rhinoplasty approach, in which case they extend to the lateral end of the lower lateral cartilages c. They may also be used in the endonasal approach, where they are used primarily to provide additional access to the lower lateral cartilage for cartilage modification. If used endonasally, they are usually combined with an intercartilaginous incision, and used to make either a pedicled (seagull) or bipedicle flap of the lower lateral cartilage and mucoperichondrium. 5. Transcolumellar a. This is used in external or open rhinoplasty b. It is made through the columella at a level just above the flared ends of the medial crura. Placement closer to the face than this is more likely to give a "dip" to the columella on lateral view after healing because there is no cartilage support to counteract the tensions generated by the healing skin. c. Many surgeons design this incision with a 'notch' in the center of the columella, to provide good landmarks for accurate closure and make the scar less obvious to the eye (a straight line is easier for the eye to follow). d. This incision is then extended into rim incisions laterally, to provide good access to the entire nasal skeleton. 6. Lateral osteotomy a. Provide access for lateral osteotomy b. These incisions are short stab incisions made just anterior to the anterior attachment of the inferior turbonate, and directed deep and laterally toward the bony piriform aperture. c. Depending on the surgeon's preference, these can be used to make subperiostial tunnels prior to the lateral osteotomies C. Septoplasty 1. Necessary component of rhinoplasty - Airway obstruction - Always done in twisted nose (Contributes to deformity) - Initial step 2. Technique a. Elevate pericondrium only on one side b. Minimal removal c. Free from bony septum d. Dorsal and caudal support e. Cross hatching technique - Weakens cartilage but not removed - Utilizes healing forces to straighten f. Splinting sutures or thin silastic. g. Nasal spine correction in caudal deviation - 3 mm chisel D. Bony Vault 1. Medial osteotomies a. Osteotome placed along side of septum (where ULC freed) and gently tapped, angle laterally at superior aspect (radix) - Change in sound with more solid bone b. When significant hump removal performed, medial osteotomes already done. 2. Lateral osteotomes a. Incision anterior to inferior turbinate b. Preserve intact periosteum except along osteotomy tract - Support, healing and smooths irregularities - Least trauma as possible - Some suggest elevating tunnel first c. Performed outside of nasal maxillary process, curving gently toward anterior surface in the last quarter of the cut d. Straighten the curved nose, freely mobile 3. Multiple lateral osteotomies - Severely twisted nose - Medial cuts done first - Indicated if nasal pyramid wider than base 4. Hump removal - Usually bony and cartilaginous - removed with rasp or chisel - Frequent redraping for visual and manual inspection 5. Augmentation a. Cartilage grafts i. Laid along dorsum - Pyramid stacks to provide smooth contour ii. Septal, conchal, rib cartilage b. Alloplastic implants -To be avoided in basic rhinoplasty V. Cartilaginous Framework A. Mid-Nose 1. Elevate the soft tissue from cartilage support with scissors - Inter or intracartilaginous incision (vs. external approach) 2. Trim septal cartilage hump if one exists - Rasp, blade, scissors 3. Free upper lateral cartilages (ULC) from septum - "Seek their own level" once freed - Trim excess - Leave lateral and cephalic attachment undisturbed B. The Tip 1. Delivery technique a. Intercartilaginous incision and marginal incision, separate skin from lower lateral cartilage with scissors, hook on inferior part of dome and pull inferiorly. Scissors placed into incision and brought out between cartilage and skin through marginal incision. b. Good visualization, exact reconstruction symmetry c. Allows removal of fibrofatty tissue from tip and morselization of cartilage 2. Rotation - bring the tip up a. Cephalic border of lower lateral cartilage trimmed - Complete strip - Leave (at least) 5mm of lower lateral cartilage intact b. Approach i. Delivery - as above ii. Split approach (intracartilaginous) incision through mucosa and cartilage, cephalic portions denuded and removed iii. Retrograde (intercartilaginous) evert nares, separate mucosa and skin from lower lateral cartilage in retrograde fashion and excise c. Point of rotation is lateral edge of lower lateral cartilage d. Caution - weakens support of tip (divides ligaments between upper and lower lateral cartilages), may cause bossae (tip irregularity) formation 3. Secondary Rotation a. Further rotation or shortening b. Secondary point of rotation is created by excising a triangle of cartilage (apex inferior, base cephalic, spares vestibular skin) in mid area of lower lateral cartilage c. Typically via delivery approach * More advanced technique - can create distortion, over rotation 4. Free Rotation - Lower lateral cartilage freed from lateral attachments and trimmed as above 5. Vertical Dome Division (Goldman procedure) a. Lower lateral cartilage separated vertically at dome area 1-2 mm from where the lateral crura meet the medial crura, repositioned, then sutured b. With or without incision of vestibular skin c. Used to reshape and refine dome, narrows bulbous tip, can increase or decrease projection (variation in placement of cuts) d. Weakens support of tip - Usually should be resecured with suture e. Irregularity of tip may develop (even years later) - Alar notching, pinched look, asymmetry f. More or less conservative - incisional vs. excisional 6. Increased Projection a. Suture technique i. Suture placed superiorly on caudal septum to lower position on medial crus to raise the tip (4.0 clear Prolene) ii Suture placed between medial crus to bring domes together narrowing and raising tip b. Grafts i. Struts - Cartilage graft placed between medial crura extending from anterior nasal spine to feet of crura or to area between the domes, sutured in place to septum and crus - Raises the crural complex and thus the tip ii. Tip graft - Illusion of raised domes, creates new tip at higher level c. Lowered dorsum gives illusion of raised tip - May be inadvertant change d. Lateral crural steal i. Technique: external approach, separation of the vestibular skin from the concavity of the domes, advance the lateral crura adjacent to the dome medially, transdomal mattress suture secures the new tip complex (bury knots between medial crura) ii. Increase the length of the medial crura at the expense of the lateral crura iii. Tip relocated in superior and anterior direction thus enhancing projection with associated tip rotation as consequence - More triangular base iv.Indication: combination of - Flattened nasal base - Poor projection - Under rotation - Amorphous, bulbous tip v. Avoid in patients with thin skin 7. Decreased Projection a. Removal of part (or all) of tip support results in lowered tip b. Removal of portion of foot of medial crura, free lower lateral cartilage, morselize dome, advance to create new (lower) dome. c. Dome truncation i. Technique: expose dome via external approach, free lower lateral cartilage from vestibular skin, advance, trim and resecure (suture) ii. Advantages - Vestibular skin continuity preserved - Accurate reconstruction restores stability - Asymmetry should be rare iii. Disadvantages - Not good for thin skin (edges of divided cartilage revealed) - Could reduce size of nasal opening d. Raising dorsum gives illusion of decreased projection. * May be undesired result of other maneuvers VI. External Approach A. Technique 1. Columellar incision (described above) connects to rim incision. 2. Elevate soft tissue at level of pericondrium of LLC and ULC 3. Superior septal angle exposed by dividing the ligaments that connect lateral cartilages together 4. Septoplasty - Unequaled exposure 5. LLC, Tip and ULC modifications under direct vision 6. Hump removal and medial osteotomies under direct vision 7. Lateral osteotomies as in closed approach 8. Closure - Resecure modified ULC to refined septum - Resecure medial crura to each other - Precise closure of incisions B. Advantages 1. Unequaled exposure of nasal elements - Delivery technique may distract normal anatomy 2. Allows subtle refinements (not just for the horrible TDC nose) 3. Facilitates symmetry 4. Teaching (learning) C. Disadvantages 1. Incision (columellar and rims) a. Scar contracture (Decreased risk by placing above flare of crus and gullowing shape) b. Unsitely scar i. Studies show inapparant in most cases (Adamson 1990) ii. ?? Patients acceptance 2. Increased time - 15-20 minutes longer (Adamson 1990) 3. Prolonged post-op edema(no difference by 6mo) VII. Complications and Avoiding Them A. Finishing Touches 1. Sutures a. Close: Septal, transfixion and hemitransfixion incisions (4.0 Vicril) b. Close: Marginal incision (5.0 chromic or gut) c. Leave open: Lateral osteotomy incision d. Dealers choice: Inter and intracartilaginous incisions 2. Packing a. Less is better - May cause cardiovascular changes, increase bleeding, hypoxia, foreign body reaction, infection - Packing should be the exception, not the rule - (Reiter et al) 2/75 patients required gel foam placement (osteotomy incision x 2), otherwise no packing b. Antibiotic ointment +/- oral antibiotic - Septic shock (Not needed in finesse technique) c. Alternatives i. Quilting technique on septum ii. Meticulous closure of incisions iii. Use of minimum trauma technique (narrow and sharp, unguarded osteotome) 3. Dressing a. Can ruin a good result if improperly done - Decreased post-op edema - Protection - Probably won't salvage a poor result no matter how well done b. Adhesive (Mastisol), tape (steri-strips), cast (Aquaplast) - Don't restrict tip (hematoma results in necrosis) - Continuous x 1-2 weeks, at night for 6 weeks 4. Ice packs and elevate head - To nasofrontal area from before osteotomies, continuous for 24 hours 5. Antibiotics a. Reasons to use - Post-op infection can be devastating - Cellulitis, sinusitis, septicemia, cavernous sinus thrombosis, brain abscess - Packing can cause sinusitis - Toxic shock - Contaminated wound b. Infections are rare (<3%) - Toxic shock syndrome (2/100,000 patients) c. Effectiveness unproven - (Weimert and Yoder 1980) No difference in infection rate of control and prophylactic groups - (Jacobsen 1988) Probably doesn't reduce risk of toxic shock - Decreases number of colonizing bacteria, but may increase number of pathogens d. Problems of use i. Allergic reactions and side effects ii. Cost iii Antibiotic resistance iv. Superinfection e. Recommendations i. Routine use not supported ii. Indications - Packing required over 24 hours (inpregnating with antibiotic ointment) - Hematoma - Immunocompromised patient - Alloplastic implants 6. Steroids a. decrease edema(intranasal and perinasal) b. decrease echymosis c. decrease pain (Hoffman, et al 1991) B. Complications 1. Hematoma 2. Hemmorrhage 3. Infection 4. Cosmetic Deformity 5. Nasal Airway Obstruction 6. Ophthalmologic Injury 7. Edema and Echymosis Appendix I Terminology Anatomic Dome - junction of medial and lateral crura Anterior Septal Angle - angle at junction of dorsal and caudal margins of septum Axis of the Dome - linear orientation of the dome as viewed from the front, in situ Bony Nasal Pyramid - bony part of external nose Cartilaginous Vault - cartilaginous part of external nose Caudal - inferior Cephalic - superior Clinical Dome - anterior-most apex of the nasal vestibule, as viewed externally Crura - plural of crus Dome of Tip Cartilage - junction of medial and lateral crura of tip cartilage Dorsal - same as anterior Dorsal Hump - convexity of the dorsum, usually both bony and cartilaginous; however, it may be either Dorsum - anterior margin of nasal pyramid Floor - posterior Glabella - flat depression in frontal bone between supraorbital ridges Inferior Septal Angle - angle or convexity formed along caudal margin of septal cartilage Lateral Cartilages - upper lateral cartilages Limen Vestibuli - line of the vestibule, junction of vestibular skin with nasal mucosa, line of junction of the cephalic margin of the lateral crus of the tip cartilage with the caudal edge of the lateral cartilage Lobule - convexity overlying both lateral crura and demarcated roughly by the supralobular (epilobular) depression, the dip between it and the alae, and the posterior margin of the infralobular protion of the columella Lower Cartilaginous Vault - corresponds to the tip cartilages and the alae Marginal Incision - an incision which closely follows the caudal margin of the tip cartilage Membranous Septum - membranous portion that attaches the columella to the caudal margin of the cartilaginous septum Nasal pyramid - external nose Nasion - point of nasofrontal suture in sagittal plane, corresponding to overlying nasofrontal angle Nasofrontal Angle - angle of demarcation between forehead and nasal dorsum, best seen in profile Posterior Septal Angle - angle at junction of caudal margin of septal cartilage with its inferior or basal border Projection - posterior to anterior distance that the tip extends from the facial plane at the alar crease Quadrilateral Cartilage - quadrangular cartilage (of septum) Rhinion - junction of bony and cartilaginous dorsums. It approximates the maximal prominence of a bony cartilaginous dorsal convexity (hump) when present Rim Incision - an incision placed just within the vestibular edge of the rim of the naris Rotation - movement of the tip along a circular arc consisting of a radius centered at the nasolabial angle that extends to the tip defining point Scroll of Lateral Cartilage - outwardly recurved portion of caudal edge of lateral cartilage Scroll of Tip Cartilage - inwardly curved portion of cephalid part of lateral crus of tip cartilage Soft Triangle - membranous triangle, facet (of lobule) Surgical Dome - surgically established dome Tip - junction of medial and lateral lower cartilages Tripod - two lateral crura separately and medial crura together form three legs of tip support Upper Cartilaginous Vault - corresponds to the lateral cartilages Vestibular Dome - concave equivalent of clinical dome Appendix II Photography 1. Reproducibility - Pre and post op - Patient to patient a. Angle (tape on floor for positioning of patient and camera and on wall for head positioning) b. Light c. Distance - frame entire head, fill the frame d. Background - blue for color film, white for black and white 2. Framing a. Full face - ears, forehead and chin b. Fill the frame 3. Positioning - Frankfurt line (top of tragus to infraorbital rim) horizontal - Vertical line from glabella to lip center 4. Poses - Frontal - Profile (x2) - Basal - Oblique (x2) - tip aligned with cheek 45% angle - Repose vs smile (tip droop) Appendix III Computer imaging 1. Video camera connected to computer allows operator to alter image 2. Careful not to promise (may foster unrealistic goals) 3. (Thomas 1989) Analysis of patients response - Most eager to participate - Improved communication - Enhanced doctor-patient relationship - Increased patient confidence in surgeon and decision to undergo procedure - Clarified what changes they could realistically expect 4. Disclaimer that surgical results may not equal computer result 5. Provides documentation * Cephalometric measurements ------------------------------------------------------------------------------- BIBLIOGRAPHY 1. Adamson PA et al. Incision and Scar Analysis in Open (External) Rhinoplasty. Arch Otolaryngol Head Neck Surg. June 1990;116:671-675. 2. Anderson JR and Ries WR, eds. Rhinoplasty: Emphasizing the External Approach. New York, NY: Thieme-Stratton Inc.; 1986. 3. Berman WE, ed. Rhinoplastic Surgery. St. Louis, MO: The C.V. Mosby Company; 1989. 4. Colton JJ and Beekhuis GJ. Rhinoplasty Analysis. The Otolaryngologic Clinics of North America. November 1987;20(4):675-698. 5. Constantian MB. An Alternate Strategy for Reducing the Large Nasal Base. Plastic and Reconstructive Surgery. January 1989;83(1):41-52. 6. Goodman WS and Gilbert RW. The Anatomy of External Rhinoplasty. The Otolaryngologic Clinics of North America. November 1987;20(4): 641-652. 7. Hoffmann DF. et al. 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