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48 / Profi le-plasty: The Bony and Cartilaginous Nasal Vault
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on still photographs. The old adage, “A picture is
worth a thousand words,” is never truer than when
using digital imaging to show the aesthetic results
that can be accomplished in a cosmetic rhinoplasty
operation. This is particularly true in relationship to
profile-plasty. Tip projection, its assessment, and the
predicted change are very easy to demonstrate with
the “soft compare” software, as is the change in the
dorsal height. The relationship of the nasal frontal
angle and the angle of the nose with the entire face
is easily modified on the computer and shown to the
patient. Rotation and shortening of the infratip lobule is more dramatic on the profile than on the frontal view. Even if the imaging is done by an assistant,
it is imperative that the surgeon engage in the process with the patient in front of the imaged pictures to
assess the patient’s perception and likes or dislikes.
The frontal view is extremely important to show
the patient the change in the width of both the lobule and the pyramid itself (Figure 4-4). Computer
imaging allows the patient to see the angulation of
the nose much more clearly than in a photograph
or even in the mirror. Whether or not the nose can
be completely straightened can be discussed, and
the patient can decide whether a straighter nose
is still a worthwhile endeavor based on the preexisting nasal base asymmetries and asymmetries
in the midface. The patient has an opportunity to
participate in determining the final imaged result,
which can be used as an operative goal by the surgeon. It is imperative that the surgeon be realistic
and honest regarding his/her own ability to effect
the changes shown in the digital image. It is equally
as important for the surgeon to show conservative
changes that may or may not be the best that the
overall result can be. The patient needs to be shown
the limitations imposed by skin thickness and other
anatomical features that can preclude a more dramatic change. This is especially true in the case of a
patient with an overly large projecting nose but otherwise small features. Patients must also understand
that they may not be able to obtain a completely
reduced nose and still maintain form and function. Some patients must accept that a significant
improvement, but still with a large nose, may be
more appropriate and harmonious with their facial
features. Using the digital imaging, patients are able
to visualize how the nasal frontal angle becomes
more obtuse with hump reduction and may, in fact,
yield a straighter line from the forehead than would
otherwise be ideal, or they may see how augmentation of a deep nasal frontal angle effects a pleasant
change with lesser hump reduction. They are able to
visualize what reducing the nasal dorsal line in relationship to the tip looks like when they desire more
than the surgeon initially would recommend. Digital imaging can show them that lowering the nasal
dorsum too much produces a poor aesthetic result
and consequently patients will accept a stronger
profile with minimal supratip depression.
There have been many discussions relating
to the legal risks associated with imaging of the
Figure 4-4. Frontal view of a computer-imaged narrowing of a wide nose.
Profi le-plasty: The Bony and Cartilaginous Nasal Vault / 49
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proposed result prior to rhinoplasty. A major con-
cern has been that patients will develop unrealistic
expectations based on the digital images and may
ultimately be disappointed, due to the variabilities
of healing and the fact that there are no guarantees
about the results. On the contrary, it has been this
author’s experience that digital imaging actually
has the opposite effect; it improves communication
between patients and the surgeon in the preoperative
setting, diminishing patients’ unrealistic expectations
and improving their comfort level for proceeding
with surgery. Furthermore, the digitally altered pho-
tographs may be printed and given to the patient for
further study and for sharing with family and friends.
This allows patients an unhurried opportunity to
consider whether rhinoplasty is right for them and
whether the proposed aesthetic results are what they
want. The photographs are given to patients after
they have signed an imaging consent, which carefully
explains that the images are a two-dimensional rep-
resentation and illustration of the proposed results,
not a guarantee of the results of the final healing.
It is very important that patients understand there
is no “implied guarantee.” The computer imaging
enhances communication between the patient and
the surgeon builds patient/surgeon rapport. It is
incumbent upon the surgeon to be honest about the
imaged results based on his/her own aesthetic evalu-
ation, what is best for the patient, and his/her abilities
to achieve the proposed result.
The Procedures of Profile-plasty
First, it is important to identify the order in which
profile-plasty is to be performed in relationship to
the rest of the rhinoplasty. The beginning of the rhi-
noplasty involves approaching the length of the cau-
dal septum as it relates to the rotation of the nasal
lobule. Shortening the length of the nose by short-
ening the septum is the initial maneuver performed.
This is accomplished by excising a wedge of the ante-
rior caudal septum greater than the posterior angle.
This will allow rotation and releases the nasal lobule
from the septal angle. A complete transfixion inci-
sion is made to begin the steps of de-projection if
this is desired in the profile-plasty. Once the medial
crural feet are released from the caudal septum and
the attachments to the septal angle are interrupted,
tip projection will decrease 2–3 mm. The surgeon
can then appreciate the significant contribution of
the cartilaginous dorsum to the profile. The next
sequence of events is to identify the cephalic margin
of the alar cartilages, either through an endonasal
delivery flap approach or an external columellar
open approach. Taking the cephalic portion of the
alar cartilages that relate to the height of the dorsal
profile is important before judging the remainder of
the profile reduction. Later tip refinements are done
after the dorsal profile is aligned. Once these initial
maneuvers are accomplished, the order of procedures in profile-plasty is:
• Dorsal skin elevation
• Pre-elevation of the mucoperichondrium on the
undersurface of the upper lateral cartilages
• Separation of the upper lateral cartilages from the
septum
• Lowering of the cartilaginous dorsal septum
• Bony profile reduction, often with an osteotome
• Bony rasping
• Placement of spreader grafts, if indicated, and
medial osteotomies performed prior to this
placement
• Medial and lateral osteotomies to reposition the
nasal bones and narrow the new, lowered dorsal
profile
The profile-plasty begins with incisional approaches and skin and soft-tissue elevation. In
endonasal rhinoplasty, the dorsum is approached
through bilateral intercartilaginous incisions connected with, at least, a high septal transfixion
incision. In an external columellar approach, the
dorsum is approached from the elevation of the
columellar skin and the lobular skin first and is connected with bilateral marginal incisions. Elevation
is continued superiorly in the supra-perichondrial
plane cephalically to the bony cartilaginous junction, where an incision is made bilaterally into the
periosteum. The remainder of the dorsal elevation is
in the subperiosteal plane up to, and including, the
nasion. The dorsal nasal skin is raised in continuity
with the periosteum from the rhinion cephalically.
Next it is imperative to begin the middle nasal
vault reduction by controlling the middle nasal
vault and preventing late contractures and depressions of the upper lateral cartilages. First the mucoperichondrium is elevated on the undersurface of
the upper lateral cartilages where they fuse with
the septum. This forms a pocket for placement of a
spreader graft and also prevents reducing the mucoperichondrium in continuity with the dorsal cartilaginous hump reduction. In extremely tall noses,
it is sometimes necessary to reduce the mucoperichondrial excess, but in most cases preserving the
50 / Profi le-plasty: The Bony and Cartilaginous Nasal Vault
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mucoperichondrium is the ideal goal. Once the
mucoperichondrium has been elevated, the cartilaginous dorsum is lowered in segments. First, the
upper lateral cartilages are released from the septum
with sharp dissection using a #11 blade. Second, the
cartilaginous dorsum is lowered to the appropriate
level in relationship to the final tip projection. Bony
profile reduction is performed prior to determining
if the upper lateral cartilages require trimming. This
is necessary if the upper lateral cartilages are redundant and not to be used as auto spreader grafts and
are contributing to persistent cartilaginous hump.
Many times, the upper lateral cartilages are left
intact and provide further mid-nasal vault width
and support.
Instrumentation for Bony
Pro le Reduction
The author’s preference is to use a guarded Cinelli
dorsal osteotome for sharp removal of the majority of the bony hump (Figure 4-5). This is started
under direct vision and then completed with external bimanual palpation. A sharp Ruben osteotome
may be used, but care must be taken to dull the lateral edges so as not to injure the dorsal nasal skin as
the osteotome proceeds superiorly into the narrow
nasal frontal angle. Once the initial bony hump is
removed, and prior to any osteotomies, rasping is
done with a series of rasps, from coarser to finer.
Most commonly, a #4 pull rasp is used initially to
lower the remainder of the bony hump, decreasing
to 3, 2, and 1 for final smoothing of the bony edges.
Occasionally, if the hump is to be reduced primarily
A
B
Figure 4-5. (A) Cinelli guarded dorsal osteotome
(used for hump reduction or profile-plasty). (B) #4
push/pull tungsten carbide rasps.
by dorsal rasping, a #6 wide dorsal rasp is used in
a pull fashion to lower the bony hump. Final rasping is done after the osteotomies are performed.
The author’s preference is to use a series of rasps,
the double-ended pull/push tungsten carbide dorsal
rasps nos. 1–6. It is sometimes beneficial to use the
push direction of the rasp to lower a very high bony
prominence. It is also important to use the push #1
and #2 rasps after the medial and lateral osteotomies
so as not to disrupt the nasal bones, pulling them
caudally, or to disrupt the nasal bone and upper lateral cartilage junction (Figure 4-6).
Figure 4-6. Lateral view of preoperative
patient and postoperative dorsal hump
reduction profile-plasty.
Figure 4-7. Frontal view of
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preoperative patient and postoperative
single spreader graft placement
correcting unilateral asymmetry and a
curved nose appearance.
Profi le-plasty: The Bony and Cartilaginous Nasal Vault / 51
Once the predicted dorsal profile line is achieved
in relationship to the tip and the facial profile, one
must consider stabilizing the middle nasal vault to
prevent future retraction of the upper lateral cartilages, which causes asymmetrical depressions or
“hourglass” deformities.
Long experience with hump removal has led
many rhinoplasty surgeons to place and use spreader
grafts for mid-nasal vault support much more frequently than in the past. Spreader grafts are placed
either after medial osteotomies are performed or
just prior to medial osteotomies, depending on the
height of the hump reduced.
Indications for spreader grafts for the mid-nasal
vault include:
3
1. Unilateral asymmetry with infracture or inward
curvature of the upper lateral cartilages. This is
the crooked nose or curved nose (Figure 4-7)
2. Bilateral inward curvature of the upper lateral
cartilages with an hourglass appearance, even
preoperatively (Figure 4-8).
3. The extremely narrow pyramid with tall mid-
dorsal hump and thin skin, to prevent late
development of the “hourglass” deformity (Figure
4-9).
Spreader grafts are best obtained from the car-
tilaginous septum if enough cartilage is present.
Spreader grafts can be made from autogenous
auricular cartilage and from costal cartilage if larger
Figure 4-8. Frontal view of
preoperative patient and postoperative
bilateral spreader graft placement
correcting hourglass appearance.
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Figure 4-9. Preoperative frontal
view and postoperative frontal
view after bilateral spreader graft
placement in patient with extremely
narrow pyramid, tall mid-dorsal
hump, and thin skin.
amounts of cartilage are needed for grafting. The
spreader grafts are sutured in place on either side of
the dorsal septum with mattressing 5-0 PDS suture
(Figure 4-10). Stabilization of the grafts can be performed using two 1-inch 30-gauge needles prior
to suturing. Placement of spreader grafts is much
more easily performed using the external columellar approach.4 When using the endonasal approach,
after complete cartilaginous hump removal, it can
be difficult to place the more cephalic mattress
suture. If the hump reduction minimally reduces
the cartilaginous dorsum, the surgeon can often
maintain a pocket of undisturbed mucoperichondrium and place the spreader grafts without requiring suturing. This can easily be done endonasally.
If the patient requires only minimal use of spreader
grafts and there is a large redundancy of upper lateral cartilage that would otherwise be trimmed, it
Figure 4-10. Bilateral spreader grafts sutured into
place on either side of the dorsal septum.
is possible to use the upper lateral cartilages as auto
spreader grafts by just partially incising the cephalic
caudal line of the upper lateral cartilages. Leaving
the mucoperichondrium intact, the cartilages can
be folded inward and sutured directly to the septum,
providing mid nasal vault width and support.
Osteotomies
Osteotomies are required after hump removal
because the patient has an open roof deformity and
a very wide nasal pyramid. It is an error not to perform lateral osteotomies and to medialize the lateral
nasal walls after hump reduction. There are various
techniques for both medial and lateral osteotomies,
and surgeons’ preferences for instruments to be used
vary. The author prefers to perform bilateral transmucosal medial osteotomies with a 6 mm curved
osteotome (Figure 4-11). Even with large hump
reduction, it is important to make sure the medial
osteotomies are completed and not left to fracture in
an unpredictable fashion. Once the medial osteotomies are performed, bilateral, internal, low curved
to high lateral osteotomies are performed. An incision is made in the mucoperiosteum just superior
to the attachment of the inferior turbinate at the
pyriform aperture. An elevator is used to elevate
the mucoperiosteum on the undersurface of the
nasal process of the maxilla and the nasal bones to
the point where the lateral osteotomy will meet the
medial osteotomy. Once the mucoperiosteal tunnels
are elevated internally, a guarded straight Nievert
osteotome is used with the guard directed medial to
A
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B
Figure 4-11. Instruments for bilateral medial and
lateral osteotomies: (A) 6 mm curved osteotome; (B)
guarded straight Nievert osteotome.
the nasal bones. This allows any oozing or bleeding
to occur internally and not externally, decreasing
swelling and bruising. Once the lateral osteotomies
are performed, the nasal bones are medialized and a
straight dorsal line is achieved from the frontal view,
closing the open roof deformity and narrowing the
nasal pyramid.
Lateral osteotomies can be performed somewhat
asymmetrically if required for different sloping
nasal bones and angulated noses. Most commonly, a
double osteotomy is performed on the sloping side
to allow the nasal bone to move inward and match
the length of the opposite nasal bone. One can
achieve straightening of the nose in combination
with septoplasty and dorsal cartilaginous spreader
grafts with these techniques. Occasionally, when the
nasal bony pyramid is deviated from the nasion to
the rhinion, either congenitally or due to trauma, a
transverse root osteotomy is required.
medial and lateral osteotomies are completed, the
nose does not move to midline, it is because a transverse cross-fracture has not occurred. A transverse
root osteotomy is performed with a 2 mm osteotome transcutaneously through a small stab inci-
5
If, after the
Profi le-plasty: The Bony and Cartilaginous Nasal Vault / 53
sion of the nasion. Once this is performed, the nose
will straighten from the nasion to the rhinion.
Radix Grafts
Determination of whether augmentation of the
low radix will be necessary is made at the time of
the consultation. As mentioned previously, it is
extremely valuable to consider augmenting the radix
so as to achieve a straight dorsal profile line with
minimum reduction of the bony and cartilaginous
parameteral structure.6 This can be accomplished
by augmenting the radix if the nasal frontal angle
is inferior to a horizontal line corresponding to the
superior palpebral fissure. This can be easily visualized by the patient and the surgeon using computer imaging prior to surgery. Profile alignment, in
both the three-quarter and lateral view, is enhanced
by the radix graft (Figure 4-12). Radix graft often
consists of a piece of cartilaginous septum that has
been morselized so that sharp edges will not show
when edema resolves. It is common to have a significant amount of edema in the nasal frontal angle
after rhinoplasty, and it can camouflage what would
be the final result if the radix graft is overly large or
has sharp edges. Some surgeons prefer dicing cartilage and wrapping it in temporalis fascia to make
sure there is no firm radix graft 6–9 months postoperatively.7 The radix graft is placed after the medial
and lateral osteotomies and final rasping have been
performed.
Complications of Profile-plasty and
Management of the Bony Nasal Vault
There can be errors of omission8 in performing
profile-plasty. One common error of omission is
failure to perform adequate lateral osteotomies,
leaving an open roof deformity or overly wide nasal
pyramid; the second most common error is leaving
a residual hump at the bony rhinion; and the third
most common is not performing adequate lateral
osteotomies to correct a deviated nasal pyramid.
Errors of commission are, unfortunately, common as well.9 Overly aggressive bony hump reduction with under-reduction of the cartilaginous
dorsum or loss of tip support creates a classic pollybeak deformity and an operated-looking nose. As
mentioned previously, failure to support the middle nasal vault can result in late contractures of the
upper lateral cartilage and an hourglass deformity
or dorsal depressions.
54 / Profi le-plasty: The Bony and Cartilaginous Nasal Vault
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A
B
Over-reduction of the bony and cartilaginous
dorsum can result in saddle nose deformities or a
“ski slope” appearance to the nose. Correction of
saddle nose deformity requires onlay grafting with
septal cartilage graft, auricular cartilage, rib cartilage, or alloplastic material, such as Gore-Tex
(polytetrafluoroethylene) (Figure 4-13). Loss of cartilaginous support via overly aggressive septoplasty
can create cartilaginous dorsal saddling or complete
loss of support of the mid-nasal rhinion due to collapse of the “K” area of the bony and cartilaginous
dorsal septum. Another error of commission is overly
aggressive augmentation of the nasal dorsum, creat-
Figure 4-12. (A) Lateral views
of preoperative and postoperative
radix graft augmentation. (B)
Oblique view of preoperative
and postoperative radix graft
augmentation.
ing overly wide nasal pyramids, irregular appearance
on the frontal view, and loss of the nasal frontal angle.
This is most commonly seen with Silastic implants
or cranial or rib grafts placed for dorsal augmentation. AlloDerm or acellular cadaveric collagen matrix
grafts are useful in thin-skinned individuals to camouflage potential dorsal area irregularities from nasal
bones, upper lateral cartilages, or spreader grafts.10
In the author’s experience, such grafts are not long
lasting and a “shrink wrap” phenomenon will occur
despite the presence of these grafts. The patient’s own
temporalis fascia is more effective in combination
with crushed cartilage
11
as camouflage grafts over the
Figure 4-13. Lateral view
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(or oblique) of preoperative
patient and postoperative dorsal
augmentation with autogenous
cartilage and Gore-Tex sheeting
to correctan iatrogenic saddle
nose deformity.
Profi le-plasty: The Bony and Cartilaginous Nasal Vault / 55
long term. Crushed cartilage can be used to soften the
rhinion and the supratip area and to provide a thicker
cushion of fibrous material between the dorsal nasal
skin and the underlying bony and cartilaginous
structure. Unilateral depressions can be corrected
with septal cartilage onlay grafting, which is beveled
and morselized so as not to show edges.
In summary, management of the bony nasal
vault in profile-plasty can be one of the more challenging aspects of rhinoplasty surgery. A carefully
planned approach and the use of digital imaging to
predict final aesthetic results can assist in achieving a satisfactory postoperative result and a happy
patient. Attention to the details of every aspect of the
profile-plasty is imperative to ensure the most natural appearance and to minimize postoperative complications. Despite every effort to minimize the need
for revisional surgery, there is a 5% to 7% chance
of unpredicted irregularity occurring in the postoperative patient.
12
Each patient needs to be advised of
this prior to undergoing rhinoplasty. Correction of
minor postoperative irregularities or asymmetries
can be done at a minimum of 6 months to 1 year
postoperatively.
References
1. Orten S, Hilger PA. Facial analysis of the rhinoplasty
patient. In: Papel ID, ed. Facial Plastic and Reconstructive Surgery. 2nd ed. New York, NY: Thieme Medical
Publsihers, Inc; 2002:361–368
2. Crumley RL, Lanser M. Quantitative analysis of nasal
tip projection. Laryngoscope 1988;98:202–208
3. Rohrich RJ, Hollier LH. Use of spreader grafts in the
external approach to rhinoplasty. Clin Plast Surg.
1996;23(2):255–256.
4. Constantinides MS, Adamson PA, Cole P. The longterm effects of open cosmetic septorhinoplasty on
nasal air flow. Arch Otolaryngol Head Neck Surg
1996;122:41–45
5. Most SP, Murakami CS. A modern approach to
nasal osteotomies. Facial Plast Surg Clin North Am
2005;13:85–92
6. Daniel RK. Middle Eastern rhinoplasty in the United
States: part I. Primary rhinoplasty. Plast Reconstr
Surg 2009;124:1630–1639
7.
Daniel RK. Mastering Rhinoplasty. Heidelberg,
Germany: Springer. 2009
8. Cobo, Roxana M.D.Correction of Dorsal Abnormalities in Revision Rhinoplasty.Facial Plastic Surgery.
Revision Rhinoplasty. 24(3):327–338, August 2008.
9. Sandel, Henry D. IV M.D. 1; Perkins, Stephen W.
M.D. Management of the Short Nose Deformity in
Revision Rhinoplasty.Facial Plastic Surgery. Revision
Rhinoplasty. 24(3):310–326, August 2008.
10. Toriumi, Dean M. MD Autogenous Grafts Are Worth
the Extra Time.Archives of Otolaryngology — Head
& Neck Surgery. 126(4):562–564, April 2000.
11. Tardy, M. Eugene Jr.; Zide, Barry M. M.D., D.M.D.
Pp. 106. Raven Press, New York, N.Y., 1990.Surgical
Anatomy of the Nose.Plastic & Reconstructive
Surgery. 88(1):165, July 1991.
12. Bagal AA, Adamson PA. Revision rhinoplasty. Facial
Plast Surg. 2002;18(4):233–244.
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Posttraumatic Nasal
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Deformity and Nasal
Fracture Management
Rami K. Batniji, MD, FACS and Stephen W. Perkins, MD
5
Introduction
In this chapter, we review the management of the
acute nasal fracture. The nasal bones are the most
commonly fractured bones in the face. Acute nasal
fracture may result in both nasal deformity and nasal
airway obstruction. However, some controversy still
surrounds the management of acute nasal fractures.
A review of the literature demonstrates a lack of
consensus about the timing of repair of the acute
nasal fracture, the anesthesia used during the repair,
and the type of procedure performed. Furthermore,
the frequency of post-reduction nasal deformities
reportedly requiring subsequent rhinoplasty or
septo-rhinoplasty ranges from 14% to 50%.
A thorough history of the mechanism of injury
and a detailed physical examination guide the surgeon in deciding how to treat the acute nasal fracture, with special attention dedicated to the septum,
because improper reduction of the injured septum
is the usual cause for the high incidence of postreduction nasal deformities.
Incidence
Nasal bones are the most commonly fractured
bones in the face. While reports estimate the annual
incidence of nasal fractures in the United States
as 52,000, the actual number may be higher for a
variety of reasons, including the fact that severely
traumatized patients with life-threatening injuries
may have nasal fractures that go unrecognized.1 The
mechanism of injury is usually blunt trauma, which
and can occur in assault, motor vehicle accidents,
falls, or sports-related injuries.2 Previous nasal surgery may affect the incidence of acute nasal fracture; a patient who undergoes rhinoplasty is at an
increased risk of nasal fracture, particularly within
the first year following the rhinoplasty procedure.
Nasal fractures in the pediatric population may
be overlooked. The pediatric nose is mostly cartilaginous and the nasal bones are small; therefore,
in comparison to the adult nose, the pediatric nose
is softer, more compliant, and less likely to sustain
displacement when fractured. Yet, pediatric nasal
fractures do occur. A review of the pediatric facial
fractures in the National Trauma Data Bank demonstrated a 30.2% incidence of nasal fractures in
children and adolescent trauma patients (ages 0–18
4
years).
The most common mechanisms of injury
are motor vehicle accidents, violence, falls, and
sports-related injuries (Figure 5-1). Another potential cause of nasal fracture in the pediatric population is birth trauma. Birth trauma, from intrauterine
forces, breech delivery, or forceps-assisted delivery,
may result in congenital deviation of the nasal sep-
5
Although the deviation can be treated easily,
tum.
expeditiously, and usually without complication in
the neonatal period, the deviated septum can be
overlooked. The pediatric nose is very susceptible
3
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