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Chapter Getting Rhinoplasty Right the First Time 165
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4. Restoration of the dorsal aesthetic lines
We have evolved a component approach to the dorsum that uses incremental
manipulation to establish well-dened and smooth dorsal aesthetic lines while
preventing undesirable dorsal deformities or internal valve collapse.
Release of the Upper Lateral Cartilages from the Dorsal Septum
Component dorsal hump reduction separates the dorsal hump into cartilaginous
and bony components as well as separating the upper lateral cartilages from the
septum and preserving the mucosa of the internal nasal valves.
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Resection of the Dorsal Septum Incrementally
e dorsal septum has a T-shaped orientation in cross-section.
Component dorsal hump reduction allows preservation of this cartilage attached
to the dorsal edges of the upper lateral cartilages while the dorsal septum is reduced. is cartilage along with the upper lateral cartilages can be resected independently from the dorsal septum, or the upper lateral cartilages can be used
as autospreader aps.
Rasping of the Bony Dorsum
Once the cartilaginous hump has been reduced, the bony hump is incrementally
reduced using a rasp. Oblique strokes are used along the dorsal edges of the nasal
bones. e dorsum should be constantly reevaluated to ensure a balanced reduction and smooth transition between the bony and cartilaginous humps.
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Restoration of the Dorsal Aesthetic Lines
2-4 mm
Preservation of the upper lateral cartilages allows for reconstitution of the midvault and restoration of the dorsal aesthetic lines and internal nasal valve. Upper
lateral cartilage tension spanning sutures are used to reconstitute the midvault.
Preservation of the cartilage has decreased the requirement for spreader gras
to reconstruct the midvault and internal valve. In primary rhinoplasty, indiscriminate use of spreader gras will lead to excessive midvault width, visibility/
palpability, and depletion of cartilage required for graing elsewhere.
Osteotomies
Superior oblique
osteotomy
Transverse fracture
Webster’s triangle
Frequently aer reduction of a dorsal hump, an open roof deformity is created
with the superior dorsal aesthetic lines appearing excessively wide. Additionally,
the bony vault may be wide or the nasal bones may be deviated. Lateral nasal osteotomies should be used judiciously to correct these deformities.
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Percutaneous perforated lateral osteotomies are our preferred technique, because
they have proved predictable and reliable for correction of the deformities discussed.
-
is procedure involves discontinuous perforations made by a sharp
mm osteotome along the lateral aspect of the bony pyramid, followed by greenstick infracturing performed with digital manipulation. e skin overlying the
maxilla at the nose-cheek junction is perforated at the level of the infraorbital rim
down to the subperiosteal plane, followed by a posterior sweep along the bone
to push the angular artery away from the osteotomy line. Lateral nasal osteotomies will close the open roof and smooth out the superior dorsal aesthetic lines
as well as the osteocartilaginous transition at the keystone area, and can adjust
the width of the base of the bony vault.
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erefore the goal of dorsal hump reduction should be twofold: () to achieve
an aesthetically pleasing lateral prole, and () to create smooth, symmetrical,
well-balanced dorsal aesthetic lines on frontal view.
USE INVISIBLE GRAFTS
Whether for tip shaping or dorsal contouring, visible gras are commonly used in
rhinoplasty. For many years, the use of visible gras has been part of the routine
as a result of inadequate preoperative analysis and a lack of familiarity or condence with alternative techniques. However, there is no clear understanding of
the long-term consequences of gras, including displacement, absorption, and
changes to the overlying skin envelope.
Although gras are frequently required during rhinoplasty, the surgeon should
make an eort to use invisible gras. ese gras provide additional structural
support and improve contour. Furthermore, invisible gras decrease the longterm consequences associated with visible gras because of changes in the gra
itself or the overlying so tissues.
We frequently use the following gras during primary rhinoplasty:
1. Columellar strut gra
2. Alar contour gra
3. Anatomic cap gra
4. Morselized onlay gra
5. Spreader gra
Although gras are frequently required during rhinoplasty, the surgeon should
make an eort to use invisible gras.
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Columellar Strut Gra
Columellar strut gras are used frequently with the
open approach. Columellar strut grafts have long
been employed as a means to increase nasal tip projection.
In our recent study consecutive patients who underwent primary rhinoplasty
with the use of a columellar strut were analyzed.
of preoperative and postoperative photographs, % of these patients actually
lost tip projection despite the use of a oating columellar strut. As opposed to
increasing tip projection, columellar strut gras appear to have more eect on
maintaining tip projection and unifying the tip complex. Additionally, the columellar strut gra can add support when the medial crura are weak.
-
,
Based on computer analysis
ere are several specic nasal morphologies that benet from the additional
support gained by placing a columellar strut gra:
1. e hanging tip
2. e dynamic tip
3. e tension tip
4. Alar-columellar discrepancies with columellar retraction
5. Irregularities of the medial crura
6. e aging nose
Alar Contour Gra
e lower lateral cartilage is the structural cornerstone for the alar rim and overall tip support. However, it is the strength, anatomic positioning, and orientation of the lateral crus that are paramount to the location, contour, and stability
of the ala. External valve collapse, notching, and retraction can all become apparent when the lateral crus is unable to provide proper support for nasal so
tissues that become further stressed with inspiratory eort. In patients with alar
rim collapse or weakness, the so triangle appears notched from lack of underlying cartilaginous support.
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For the past two decades we have used alar contour gras as a simple yet eective rhinoplasty technique for improved contouring of the alar rim; this involves
nonanatomic insertion of an autologous cartilage gra into a pocket along the
alar rim. e alar contour gra provides a foundation for reestablishment of
a normally functioning external nasal valve and an aesthetically pleasing nasal
tip and alar contours. e use of alar contour gras decreases the risk of alar deformities including alar notching or retraction, as well as excessive concavity or
convexity of the alar rim.
More recently, the extended alar contour gra has been used to prevent notching of the anterior alar rim where the lateral crus begins to diverge from the alar
rim as it courses to the piriform aperture. Additionally, the extended alar contour gra can inuence the rotational orientation of the lateral crus so that the
caudal and cephalic borders are rotated into the same horizontal plane, further
inuencing the tip and alar contours.
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Anatomic Cap Gra
Visible tip gras used to be a mainstay of tip shaping during rhinoplasty. However, with the widespread use of tip-suturing techniques and their versatility, we
use visible tip gras much less oen. Instead, if a small degree of tip contouring
or volume augmentation is desired aer tip suturing is completed, an anatomic
cap gra can be used.
,
Cartilage resulting from the cephalic trim of the lower
lateral cartilage can be used to fashion an anatomic cap gra. is cartilage gra
is typically thin and pliable, so it contours over the tip very well, and it does
not have any distinct edges, so palpability and/or visibility of the gra is not a
problem.
Morselized Cartilage Onlay Gra
Morselized
cartilage graft
Extended alar
contour grafts
In areas that require minimal augmentation or improvement of mild irregularities of the osteocartilaginous framework, morselized cartilage onlay gras can
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be placed. e cartilage is morselized in a cartilage crusher and can range from
being slightly bruised (to make it less rigid and more conforming without sharp
edges) to crushed into a thin sheet (that can act as a scaolding for tissue ingrowth). Morselized cartilage onlay gras can be used anywhere for augmentation or correction of mild irregularities. We have most commonly used it as a tip
gra or along the dorsum for dorsal irregularities.
Spreader Gra
Spreader grafts
Spreader gras are used to reconstitute the dorsal aesthetic lines, correct dorsal deviation, enhance nasal length, and reconstruct the internal nasal valves.
Preservation of the cartilage has decreased the requirement for spreader gras
to reconstruct the midvault and internal valve. In primary rhinoplasty, indiscriminate use of spreader gras will lead to excessive midvault width, visibility/
palpability, and depletion of cartilage required for graing elsewhere. Spreader
gras should only be used when necessary. We most commonly use unilateral
or bilateral placement of spreader gras for correction of dorsal deviation or reconstruction of the internal valves.
THE BEST CHANCE TO GET THE RESULT IS DURING PRIMARY
RHINOPLASTY
Primary rhinoplasty oers the surgeon a unique opportunity to manipulate undisturbed tissue planes and native anatomy to produce a result that meets both
aesthetic and functional goals. It is during this rst nasal surgery that the opportunity to achieve the best result exists. Subsequent procedures are technically
more dicult and less predictable for a multitude of reasons. Scarring within the
nasal so tissue envelope can create irregularities, brotic and inelastic skin, and
thinner or thicker skin in certain areas. Alterations in the underlying osteocartilaginous framework during previous surgery leads to the potential for inadequate structural support. Cartilage is oen required during secondary rhinoplasty; however, adequate cartilage for graing may no longer be available in the
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nose, necessitating harvest from remote sites, including the ear and ribs. Finally,
and what is most important, the patient’s emotional state is oen quite dierent
when presenting for primary versus secondary rhinoplasty. In many instances,
the patient requiring a secondary procedure is upset over his or her previous
surgery, and this may result in challenges establishing trust, which is critical to
the doctor-patient relationship.
Primary rhinoplasty oers the surgeon a unique opportunity to manipulate undisturbed tissue planes and native anatomy to produce a result that meets both
aesthetic and functional goals. It is during this rst nasal surgery that the opportunity to achieve the best result exists.
FOLLOW PATIENTS LONG TERM
Expertise and experience are gleaned from critical analysis of one’s own results.
We learn through analyzing factors that play a role in a successful rhinoplasty.
We learn even more from shortcomings or failure to achieve the desired goals
of surgery.
Looking back critically at a -year experience with primary rhinoplasty, the
goals of surgery were more frequently met as more experience was gained:
First years
Next years
Last years
Actual revision rate
Could revise %
Could revise %
Could revise %
.%
e results of certain techniques were maintained over the long term, whereas
others did not hold up well over time. By critically examining our long-term results, we have found that the early results using visible gras had the potential
to develop late deformities from changes in the gra themselves or their displacement. Additionally, techniques that preserve cartilage when possible and/
or provide additional structural support, such as columellar strut gras and alar
contour gras, improve longevity of the result aer rhinoplasty. Our approach
has evolved to apply the information gathered from these observations to provide
increased consistency and longer durability in results aer primary rhinoplasty.
Expertise and experience are gleaned from critical analysis of one’s own results.
We learn through analyzing factors that play a role in a successful rhinoplasty;
what is more important, we learn even more so from shortcomings or failures to
achieve the desired goals of surgery.
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