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Three-point sutures placed on medial crura and caudal septum.
(b) Additional refinement of the nasal tip projection.
Medial crural sutures are usually the first sutures placed in tip
rhinoplasty, with the goal of correcting flaring, columellar width, and crural
asymmetry. The primary placement of these sutures is necessary to create a
stable columellar base prior to additional tip suture augmentation. The
location will determine on the underlying deformity to be corrected,
although they are often placed in the middle third of the medial crura to
fixate a columellar strut graft (described previously) [52, 58] (Fig. 8).
Fig. 8 Medial crural sutures [59]
Transdomal sutures are more commonly modified to hemidomal sutures
with modern rhinoplasty, fastened to the dome as opposed to the more
posterior columella. This can help to reduce inversion of the nasal rim as it
occurs with overtightening of the knots [55]. Infiltration with tumescent
anesthetic solutions containing Xylocaine and epinephrine is utilized to
reduce bleeding and pain when necessary. Generally, surgeons use a 5–0
nylon suture to bite into the cephalic dome at the lateral LLC, then tie the
suture at the medial aspect (about 4–5 mm from the first). It may be
necessary to grab the cartilage at 3 or 4 points to accomplish the desired
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convexity, which should be assessed with temporary skin redraping after the
first suture is placed. The interdomal narrowing may be enhanced with
fastening of transdomal suture tails along the midline. [54, 60] (Fig. 9).
Fig. 9 Transdomal sutures [61]
The lateral crural steal is a modification of transdomal tip sutures and is
well utilized in tip projection for patients with a preoperative drooping nasal
tip. The sutures are placed into the further from the midline into the lateral
crus, using more cartilage to create the domal structure. As it results in
increased shortening of the lateral crus and lengthening of the medial crus,
the upward tip rotation can be accomplished to a greater degree, as well as
narrowing of the alar base width [62].
The interdomal sutures are usually placed after hemidomal sutures, as
they can lend to the appearance of a flatter, droopy nasal tip when used
alone. With this technique, vertical uninterrupted sutures (5–0 nylon) are
placed bilaterally about 3–4 mm inferior to the upper domes into the
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cephalic middle crurae of the LLCs. In some cases, an additional suture will
be placed below when additional columellar narrowing is indicated.
Commonly, the “tongue-in-groove” modification of medial crural septal
sutures is utilized in patients indicated for nasal tip lengthening and
improved tip projection. This modification is performed with open or
endoscopic rhinoplasty with placement of bilateral extended spreader grafts
(CSEGs) and columellar strut grafts. Sutures are placed at the septum to
fasten the CSEGs, and at the medial crura to position the columellar strut
grafts in the newly created intercolumellar space. These sutures are usually
placed more loosely if creation of a supratip break (gap between lateral crus
and caudal septum) is indicated [56, 63–65].
Patients with preoperative alar rim defects secondary to previous
rhinoplasty or congenital alar collapse may be indicated for additional
support with placement of lateral crural strut grafts and/or alar contour
grafts. The increased stabilization of nasal tip structures can help maintain
the integrity of the external nasal valves. The indications and surgical
techniques for alar contour grafts and lateral crural strut grafts are well
detailed in the literature, cited here for reference [66–70].
2.4 Complications and Outcomes
The most common complications after surgical rhinoplasty are bloodrelated, including nasal bleeding (epistaxis), hematoma, or severe vascular
damage. Often, the impact of dissection and incision induces postoperative
bleeding in the earlier healing process. Patients are recommended to use
topical nasal sprays (oxymetazoline) and keep their head elevated. In cases
of moderate blood loss, internal pressure on the nasal cavity using
absorbable or non-absorbable packing may be indicated. Trauma to the
sphenopalatine arterial network is thought to occur in less than 1 in 100
individuals, although this should be considered when patients experience
persistent heavy bleeding. Hematoma formation is an urgent complication
and should be drained as soon as possible to avoid long-term deformities,
cartilage necrosis, and decreased support (Saddle nose) [71–75].
Infection is an additional consideration, with the potential to progress
into cellulitis, abscess formation, or necrosis if untreated. Oral antibiotics
are well utilized in treating cellulitis of the soft tissues, but intravenous
antibiotics and tissue excision are generally the first-line therapy for abscess
formation. There are cases documented in the literature of meningitis,
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cavernous sinus thrombosis, and brain abscess formation secondary to
rhinoplasty infection, but these are few and far between [76]. Patients who
colonize methicillin-resistant Staphylococcus aureus are suggested to have
an increased risk of clinical infection. Use of preoperative mupirocin
ointment for 5days preoperatively is well utilized in reducing MRSA
colonization before rhinoplasty, and has been shown to reduce infection
rates by 50% in these patients [77–79].
Soft tissue complications are minor in most cases and can be attributed
to occlusive dressings or splint placement. Some patients have certain
allergies to the ingredients in adhesives and will experience redness or
irritation (contact dermatitis) after exposure. Generally, these are managed
with gentle skin cleansing and/or use of topical cortisone [80, 81]. Rare
cases of skin necrosis are generally precipitated by improper technique
(excessive thinning of subcutaneous tissues), overly constrictive dressing
placement, poor healing after infection, and/or perioperative tobacco or
nicotine use [72].
Weeks or months after surgery, nasal tip instability and poor tissue
scarring will gradually develop in affected patients. These outcomes are
noted at continued follow-up appointments, although the patient may notice
much earlier. Individuals that have darker skin pigmentation or are
predisposed to hypertrophic scarring should receive special attention
regarding the placement and closure of surgical incisions, with emphasis
placed on minimizing tension. Keloids are more likely to form in these
individuals and can be treated with 5-fluorouracil injections or steroids [73,
76, 82, 83].
Septal perforations may occur in up to 3% of patients and are frequently
attributed to aggressive submucosal dissection and/or cartilage harvest. If
mucosal tears are present after the procedure is completed, they should be
closed on at least one side to prevent the development and/or worsening of
postoperative perforations [72, 73].
When osteotomies or resection of the dorsal hump is performed, the
ULCs may destabilize or detach from the caudal nasal bones, lending to
inferomedial migration of tip cartilage. This lends to the appearance of an
inverted V-shaped shadow on the dorsum, subsequently referred to as the
inverted V deformity. Surgeons should recognize decreased support of the
osseocartilaginous midvault either before or during the surgery and provide
additional tip support with spreader grafts [76].
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Pollybeak deformities are relatively common, contributing to more than
half of revisional rhinoplasties in some studies [84–86]. This deformity
occurs when the nasal tip is not adequately projected relative to the dorsum,
or when it is not supported adequately throughout the healing process. Most
commonly, it is caused by failure to lower the cartilaginous dorsum at the
ASA. Scarring in the supratip region may occur with dorsal reduction,
lending to the appearance of a drooping nasal tip. Steroid injections may
help to avoid revision rhinoplasty if they are administered before permanent
results are established [87].
Rhinoplasty is more commonly performed in women, although the most
common primary motivation documented in both genders involves prior
nasal fracture [88]. The task of estimating postoperative patient satisfaction
is complicated by inconsistencies between surgeon and patient aesthetic
assessment. Especially with rhinoplasty, success based upon objective
physical assessment is not always indicative of patient satisfaction [89, 90].
Most patients described dissatisfaction with aesthetic augmentation
secondary to residual dorsal hump regardless of gender. Other common
reasons specified by unsatisfied patients include under-rotation of the nasal
tip, bulbous nasal tip, and large nose. Female patients tend to be more
concerned with the proportions and structure of their nasal tip and are more
likely than men to express dissatisfaction with bulbous, pinched, or underrotated postoperative tip [88]. Generally, the lower third of the nose is most
implicated with patients who express dissatisfaction.
The recent use of piezotome dorsal reduction in surgical rhinoplasty has
been shown to increase postoperative patient satisfaction while decreasing
morbidity resultant from osteotomy/aggressive reduction. Improved
stability of the osseocartilaginous nasal structures can be preserved with
this technique, theoretically reducing the risk of pollybeak or inverted V
deformities and subsequent revisional rhinoplasty [91].
While these adverse effects are considered to impact a small percentage
of rhinoplasty patients, suboptimal aesthetic and functional outcomes are a
common source of postoperative litigation. Rhinoplasty has been listed as
the most litigated aesthetic surgery, with most cases based around undesired
aesthetic appearance after surgery. This data indicates a need for
improvement in patient-surgeon communication and encourages the use of
thorough and clearly presented consent forms [71, 72, 92, 93] (Figs. 10 and
11).
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Fig. 10 Results of rhinoplasty with placement of a nasal sill graft to improve lower nostril symmetry
are shown in the left image [94]
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Fig. 11 3D preoperative planning can be used to create molds, which will be used intraoperatively to
assess the efficacy of changes made. Improved predictability of results can help to optimize the
postoperative outcome and manage patient expectations [95]
3 Genioplasty
Contour augmentation of the lower face can significantly improve the
overall facial balance and aesthetic appearance. Genioplasty, or chin
augmentation, is a procedure which can improve the lower facial contour in
good candidates. Hyaluronic acid, hydroxyapatite, and fat grafting fillers
are well utilized in semi-temporary chin augmentation, although the results
are often not as dramatic compared to more invasive techniques [96].
Surgical chin augmentation using implants, osseous genioplasty, and
mentum reduction improves the projection of the chin and jawline [97, 98].
Any corrections to the chin should be made with consideration to
proportions of adjacent facial structures, namely the lips, teeth, and nose
[99].
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3.1 Discussion of Relevant Anatomy
The soft tissue layer of the chin is composed of superficial skin, muscle,
adipose tissue. Contour and shape of the chin and medial jaw is largely
determined by the structure of the underlying mental skeleton (anterior
mandible). Three bony landmarks are notable for the shape of the chin, with
the pogonion projecting centrally and anteriorly, the menton inferiorly, and
the paragonion laterally [100] (Fig. 12).
Fig. 12 The pogonion, menton, and gnathion are indicated, along with other prominent facial
landmarks used to assess the osseous tissues. Recent advancements have allowed for the use of
cephalograms to predict necessary changes for adequate augmentation [101]
Knowledge of the neurovascular anatomy, especially the mental nerve,
is key to avoiding sensory deficits of the cutaneous chin and lower lip
mucosal tissues. The inferior alveolar nerve branches from the third
division of trigeminal nerve (CN5), and passes through the mandibular
canal before emerging as the mental nerve. Bony osteotomies for
mandibular reduction, as well as dissection/placement of implants, should
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avoid the mental foramen (at least 5 cm inferiorly) to prevent injury to the
emerging nerve fibers [102].
Mentalis muscles originate from the upper mandible (just inferior to
attached gingiva of the central/lateral incisors) and insert into the mental
skin pad. The relationship to adjacent structures is detailed in a previous
section [103].
3.2 Preoperative Patient Assessment
There are variations in gender which should be considered when planning
chin augmentation, as the wider, angular male chin requires different
techniques than its narrower female counterpart [102]. Generally, aesthetic
chin augmentation should not be performed until bone growth has
stabilized. Most surgeons wait until the patient is at least 15years of age, as
the underdeveloped dentition incurs additional risk of damage with
osteotomy [104].
The integrity of bony tissues should be assessed, especially in elderly or
malnourished individuals with poor bone quality. Generally, less invasive
implant placement is preferred to osteotomy or bone graft placement when
the integrity of osseous tissues is questioned. Smoking, diabetes, and
additional patient-specific factors which slow or impede wound healing are
generally contraindicatory [104].
As previously discussed, the structure of the chin should be carefully
considered in conjunction with surrounding facial features (nose, lips,
jawline). In some cases, genioplasty would not correct the underlying facial
deformity. The dental morphology is considered, using angle classification,
to establish dentition and identify malocclusion. Aesthetic deformity of
Class 1 Occlusion (discussed in 4.5 Orthognathic surgery) may be corrected
through chin augmentation as a standalone procedure [102, 105].
Aesthetic deformities related to anteroposterior (horizontal) bony
deficiency can be corrected with implant augmentation or bone grafting,
and individuals with superoinferior (vertical) or transverse deformities are
indicated for osteotomy (osseous genioplasty) [106].
Previously discussed guidelines with regard to surgical comorbidities
and medication (e.g., blood thinners) apply here, although there are
particular considerations to be emphasized in preoperative examination of
genioplasty candidates. Past medical and surgical history should be
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obtained in detail, including history of traumatic injury, oral surgery, or
braces/orthodontic treatment [107].
Examination of facial proportions from the frontal and lateral (side
profile) view can provide indications for appropriate augmentation
methods. Relevant measurements and methods of assessment are detailed in
Table 3 [104, 108–110].
Table 3 Frontal view assessment
Frontal view Ideal measurement Dysmorphology Indicated augmentation
Lip placement Resting lip closure Lip incompetence
Open bite
Osseous genioplasty
preferred to implant
augmentation
Facial
proportions
Equal vertical length of lower
and middle facial thirds
Long face growth
pattern
Increased incisor
show
Mentalis m. strain
Short face growth
pattern
Decreased incisor
show
Indicative of
maxillomandibular
skeletal dysmorphology,
usually better corrected
with orthognathic surgery
Mandibular
and chin
symmetry
Symmetrical chin and soft
tissue volume/contour
bilaterally
Asymmetry of chin
and mandible
Osteotomy and/or
variations to
augmentation are
indicated
Side profile
Labiomental
fold
Upper third-middle third
junction (measured thirds of
vertical distance between
stomion and menton)
Vertical fold distance: about 6
mm in women and 4 mm in
men
Deep fold
Horizontal
augmentation
May present with long
lower face
Shallow/imperceptible
fold:
Vertical augmentation
Deep folds with long
lower face indicate
orthognathic correction
and contraindicate
primary genioplasty
augmentation
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