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Fig. 4 The frontal and lateral landmarks, which are observed at the preoperative consultation [31]
Additionally, the surgeon will examine the columellar structure and alar
insertion from a basal view. The outline of the ideal nasal base is triangular,
without the presence of a bulbous or boxy infratip lobule. A trapezoidal
nasal base may be indicative of intermediate crural divergence. Ideally, the
infratip lobule comprises the upper third, and columellar structures form the
lower third. This basal view provides additional information about the
nostrils, which should be teardrop-shaped and angled medially [26, 27].
Age, gender, and ethnicity lead to variations in these measurements,
whether genetic or due to changes/degeneration. With aging, thickening of
nasal tip skin and resorption of cartilage can induce the appearance of a
drooping nasal tip [32].
2.3 Surgical Techniques
Modern rhinoplasty incorporates various techniques to reconstruct the nose,
allowing for individualized augmentation. Reduction or augmentation of the
midvault (ULCs, dorsal cartilaginous septum), dorsum, and/or septum allow
for optimization of the lateral and frontal aesthetic appearance. Osteotomy
is useful in narrowing the nasal bones or correcting deformities.
Augmentation of the nasal tip and adjacent cartilaginous structures (alar
cartilage, columella) may be performed as a standalone procedure or
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incorporated into reconstruction of the midvault, dorsum, septum, or nasal
bones. Smaller augmentations of the tip, alar, and columellar tissues
required more delicate techniques, and these techniques are incorporated
after the midnasal reconstructions are completed in most cases [30]. Access
to the osseocartilaginous vault can be accomplished with open and closed
incisional approaches. Although some surgical maneuvers should be
performed with open rhinoplasty, surgeons generally prefer the closed
incision technique for an uncomplicated patient [33].
Open rhinoplasty utilizes an externally visible transcolumellar incision
through cutaneous tissues to access the infracartilaginous planes. Open
incisions allow for improved access and visibility of the nasal framework,
although they incur risk of unaesthetic scarring with improper wound
closure or infection [34]. The closed, or endonasal, incisions are made
along the medial nostril just inside the nasal cavity. Superficial skin is
preserved and lifted from the cartilage in a suprafacial plane, avoiding
externally visible incisions [35] (Fig. 5).
Fig. 5 (a) The open marginal and transcolumellar incisions; (b) the endonasal approach [31]
2.3.1 Dorsal Reduction and Augmentation
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Dorsal reduction techniques are generally categorized as composite or
component reduction. Composite reduction utilizes simultaneous resection
of the nasal bones, perpendicular plate, upper lateral cartilages, and dorsal
septum. In the supracartilaginous plane, proximal septolateral cartilage is
trimmed with a scalpel along the pre-planned dorsal trajectory to the nasal
bone, leaving trimmed tissues attached cranially. A straight-cutting
osteotome or chisel continues trimming along this pattern (ideally with one
incision), and uneven or sharp edges are refined using a medium-fine rasp
[36].
Component reduction is preferred by some surgeons for its advantages
of improved control and selective subunit preservation [36, 37]. Composite
and component techniques use similar reduction methods, although the
latter involves an additional maneuver to separate the ULCs from the nasal
septum prior to trimming. The component technique keeps the ULCs intact
when possible, reducing the risk of middle-vault open defects resultant of
septolateral cartilage trimming [38].
Recent medical advancements have shown success in dorsal reduction
using ultrasonic surgical units, namely Piezotome I and II, with open
rhinoplasty technique. The idea is to reduce swelling and postoperative
complications that result from aggressive bone removal techniques.
Dissection of the cutaneous soft tissues is performed in the
supraperichondrial plane, transitioning to a subperiosteal dissection with the
ultrasonic elevator tip at the nasal bone. After the tissues have been elevated
from the bony hump, reduction and augmentation are performed with the
ultrasonic nasal bone reduction tip [39].
Middle-vault open defects, commonly referred to as open-roof
deformity, can be corrected with lateral osteotomy or infracturing of the
nasal bones. These techniques allow for simultaneous narrowing of the
dorsum and would not be well utilized for individuals with preexisting
narrow dorsum and/or those indicated for nasal valve opening [30].
Indications for dorsal augmentation are described in the previous section,
although the extent of projection will determine which techniques should be
implemented. Insufficient dorsal projection indicates thorough preoperative
assessment of structural midvault integrity, especially in cases of saddle
nose deformity.
Grafts are the traditional method used for dorsal augmentation, whether
to correct a defect or improve the aesthetic appearance of the nose from
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frontal and lateral views. When a wider dorsal width is indicated (for
aesthetics or otherwise), spreader grafts are used to support the trimmed
dorsum. Graft augmentation uses cartilage grafts from the patient’s own ear
(conchal), septum, or rib (costal) to widen and project the dorsal contour
and/or stabilize the nasal structures. Osseous rib tissue or fascial tissue
structured with crushed cartilage may additionally be utilized for
augmentation of the dorsum or radix. Studies investigating the efficacy of
acellular crosslinked dermal matrices (ADM) show promising initial results
in dorsal augmentation. An overall patient satisfaction rate of 80% was
obtained in one study, with no documented complications [40].
Autospreader grafting is a well-utilized technique for patients with
excess dorsal ULC cartilage, as it does not require harvest of cartilage from
a donor site. Excess cartilaginous tissue is brought over the nasal septum,
then fastened in place using variable suture placement. Curving over of the
ULCs in a single layer provides the greatest amount of dorsal width.
Patients who would benefit from a narrower dorsum but require improved
midvault stability and/or open roof defect correction are indicated for
modified autospreader grafting, in which the excess tissues are infolded
prior to fastening [30]. Spreader graft placement is another technique to
keep the dorsum narrow while providing stability, which is discussed in the
following [41].
While the use of autospreader grafting technique avoids the need for
local/distal tissue harvesting, it is not as useful for correction of the deviated
nose, collapsed internal valves, or narrow preoperative midvault [21, 42].
The prepared tissues are shaped and inserted into a submucoperichondrial
pocket between the dorsal septum and ULCs. Sutures (5.0 horizontal
Maxon/polydiaxonone) may be necessary to fasten the graft in place,
especially if the mucosal tissue attachments to cartilage have been disrupted
during surgery. Unilateral placement of a spreader graft corrects minor
asymmetrical deviation or unaesthetic concavity/constriction and may also
be used bilaterally to reduce the inverted V deformity. The latter is resultant
of the disruption of ULC-nasal bone junction, often with trauma or previous
rhinoplasty [30, 43, 44].
Grafted cartilage tissue from the septum is shaped into an inverted V or
U prior to pocket placement, while costal (rib) cartilage is prepared with
concentric shaping and secured in two places. Rib cartilage fixation often
necessitates wire fastening at the radix and suture attachment at the ASA as
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these tissues are subject to warping and postoperative deformities. In
addition, careful feathering of the cephalic attachment near the radix is
indicated, to avoid creating palpable and/or visible deformity under the
thinner skin [45].
Augmentation of the radix can be accomplished with cartilage grafts,
although the thinner skin at this location makes it difficult to camouflage
the inserted tissues. Soft tissues allow for improved concealment of grafts,
although they may not produce as great a degree of augmentation and are
resultantly used for smaller deficiencies (1 mm or less). Alloplastic
implants are another option for dorsal or radix augmentation, including the
ePTFE (Gore-Tex; W.L. Gore and Associates, Inc., Flagstaff, Arizona).
Alloplastic ePTFE grafts have been well utilized in the past, with minimal
documentation of adverse effects [21, 42].
2.3.2 Septoplasty
The septum and its affiliated structures play a large role in the aesthetic
appearance and function of the nose. The ASA (anterior septal angle) is a
major determinant of nasal tip rotation and orientation, while the
appearance of the columella (whether extroverted or retracted) is a result of
the caudal septal structure [42].
After adequate dorsal reduction, the septum is accessed through
submucoperichondrial tunnels (endoscopic approach) or separation of the
ULCs from the dorsal aspect (open approach). Cartilaginous tissues are
harvested from the septum at the bony interface (maxillary crest,
perpendicular ethmoid plate, vomer) with a swivel knife, D knife, or 15blade scalpel, leaving the L-strut (10 mm of dorsal and caudal septum)
intact to ensure stability. Grafts are used if necessary to stabilize the
septum, and harvested quadrangular cartilage is well utilized for this
purpose [46] (Fig. 6).
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Fig. 6 Septoplasty techniques are illustrated in the figure above, in which the ULCs are separated (a,
b) and refixated linearly (c) with sutures [31]
Individuals with severe deviations may benefit from an extra-corporeal
septoplasty, in which the entire septum is removed and reshaped prior to
reinsertion. In these cases, the septum should be refixated to the ANS at the
caudal aspect and nasal bones/ULCs at the proximal dorsal aspect to avoid
saddle nose deformities [46].
Deviated septum anomalies can often be attributed to irregularity,
asymmetry, or malpositioning of the bone and/or cartilaginous structures,
lending to C or S-shaped deformities from a frontal view. The general
stepwise repair of septal deviations is listed in the following [51, 52]:
1.
The osseocartilaginous skeleton is exposed, and cartilaginous tissues
(ULCs, LLCs) are dissected and separated.
2. Septoplasty is performed to correct any septal deviations, maintaining
the L-strut and using grafts when applicable.
(a)
Dorsal septal deviation may require complete separation of the
caudal septum at the posterior septal angle (PSA) and
reattachment along the midline.
(b)
Grafts can be placed to correct areas of septal concavity.
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(c) Airway narrowing secondary to septal repositioning is corrected
with outfracture/ablation of the turbinates.
3.
Unilateral medial and/or intermediate osteotomy, followed by lateral
osteotomy to allow for lateral displacement of the medialized nasal
bone (deviated to the midline).
4.
Medial and/or intermediate osteotomy is performed on the opposite
side, allowing for upper mobilization and leverage to straighten both
sides.
5.
Lateral osteotomy on the remaining side is used for complete
mobilization, allowing for complete straightening of the bones.
2.3.3 Osteotomy
Osteotomies are performed to mobilize the upper nasal bones, functioning
to close an open roof deformity (as mentioned with dorsal hump reduction)
and correct bony asymmetries. It is important to maintain the integrity of
the periosteum, as it contains any displaced bone fragments during removal
and prevents airway obstruction. Indicated incisional access to the
periosteum varies between patients, with described approaches including
endonasal, percutaneous, open rhinoplasty (elevation of periosteum and
overlying soft tissues), or intraoral (through the gingivobuccal sulcus).
Varying trajectories of augmentation are utilized depending on the
deformity: high-low-high (HLH), low-low (LL), or low-high (LH) [47].
Medial osteotomies are used for detachment of the nasal bones from the
septum. Oblique (angled) medial approach reduces fracture irregularities
resulting from superior lateral osteotomy and is better suited for complete
(caudal and cephalic) nasal wall separation. If widening of the nasal vault is
indicated (such as with placement of spreader grafts), medial vertical
osteotomy is used to separate the nasal bones from the bony septum.
Intermediate osteotomies fracture the nasal bone between the medial and
lateral aspects and should be performed before lateral osteotomy. These are
well utilized to narrow the nasal bones, straighten severely convex nasal
bones, or correct an elongated unilateral sidewall. Lateral osteotomies are
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performed after medial and/or intermediate osteotomies, separating the
lower nasal bones from lateral structures and allowing for complete
mobilization [30] (Fig. 7).
Fig. 7 Endonasal lateral osteotomy (a1) and percutaneous lateral osteotomy (b1) [31]
Webster’s technique for HLH osteotomy considers the thickness and
stability of bony structures in the nose. The initial upward trajectory avoids
disruption of the inferior turbinates to maintain an anterior bony triangle
(Webster’s triangle), which is followed by low trajectory lateral osteotomy
of the thicker maxillary nasal processes. At the level of the medial canthus,
an upward trajectory at the nasofrontal suture helps to reduce infracturing
and unaesthetic protrusion superiorly (Rocker deformity) [48].
Perforating osteotomies are indicated for patients who require maximal
periosteal support and/or lateral augmentation of the nasal bones.
Discontinuous punch osteotomies along the fracture line, which allow for
weakening and separation of the osseous septal attachment prior to
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refixation in the designated plane. Previous investigations of continuous
and perforating osteotomy techniques documented in the literature identify
perforating osteotomy as the superior technique for preservation of
periosteal and mucosal tissues [49, 50].
2.3.4 Tip Rhinoplasty
The cephalic trim, or resection of lateral crus at the cephalic border, is
generally the first step in tip rhinoplasty. This technique is almost always
performed after the osseocartilaginous vault has been augmented. Trimming
the lateral crus allows for tip and LLC separation from the midvault and
ULCs and facilitates tip manipulation/repositioning. It is important to
consider the functional integrity of the nasal valves, and it is generally
recommended to keep 6–8 mm of lateral crus intact. [30]. Trimming the
lateral crus improves tip rotation while decreasing supratip/tip fullness,
although it should be noted that cephalic malposition or flared crus requires
sutures or grafts [30, 52].
The placement of a graft between the medial crura, referred to as a
columellar strut graft, helps to support the nasal tip and improve
symmetrical augmentation. This is usually done after cephalic trimming,
and it is beneficial in stabilizing the reconstructed nose and increasing tip
projection [49, 50]. Columellar grafts may be used as floating, long, and
long stabilized struts, with their specific indications detailed by Rodrich et
al. [53]. Floating strut grafts are placed about 2–3 mm anterior to the nasal
spine and held in place by a medial crural suture and two bilateral
interdomal sutures. Fixed grafts are prepared from costal cartilage and
secured to the nasal spine using threaded Kirschner wire. It should be noted
that floating struts increase tip projection by 1–2mm, while fixed grafts
provide 3 mm (or greater) of additional tip projection [54].
Septal extension grafts are used when precise control of the nasal dome
height is indicated and can be used to maintain a 6–10 mm domal elevation
from the dorsum plane, while stabilizing the nasal base. In the event of
midvault collapse, prior placement of septal extension grafts may be
beneficial in the continued maintenance of tip projection. This technique is
often performed in patients who present with columellar retraction, as the
improved tip stability helps to reduce this appearance [55, 56]. The graft
can be prepared from harvested septal cartilage (septoplasty) and is
designed to extend dorsally to the tip of the nose and caudally to the edge of
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the cartilaginous septum. There are a few options for CSEG placement, and
they may be fastened posteriorly on the dorsum as extended spreader grafts,
directly over the ASA over the L strut, and on the caudal septum.
Anteriorly, they will be fastened to the LLC tripod complex, in a manner
which accommodates patient-specified goals and aesthetic outcome. Tip
suturing techniques, which allow for placement of interdomal and
transdomal sutures (discussed below), add 1–2 mm of tip projection and
help to stabilize columellar strut grafts or CSEGs [54, 55, 57].
Tip suture augmentation is another technique used for aesthetic
correction of the nasal tip. Generally, tip suture augmentation proceeds with
the following approach [30, 54]:
1.
Medial crural sutures.
(a)
Horizontal mattress sutures placed between the medial crura.
(b)
Used to stabilize columellar strut grafts and alter cartilaginous
tripod base.
2.
Transdomal sutures.
(a)
Horizontal mattress sutures placed between medial and lateral
aspect of each LLC.
(b)
Used for domal augmentation and tip projection.
3.
Interdomal sutures.
(a)
Horizontal mattress sutures placed between middle crura of
LLCs.
(b)
Unify bilateral cartilages for interdomal narrowing, improve tip
definition.
4. Medial crural septal sutures.
(a)
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