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Piercing
Unilateral(a)
Red eye
Watery eye
Dry/runny
nose
Ptosis
DIAGNOSIS AND MANAGEMENT OF FACIAL PAIN
Burning
Figure 45.1 (a) The features of cluster headache showing trigeminal autonomic symptoms that
may be confused for a sinogenic aetiology. (b) Facial map of the patterns of distribution of midfacial segment pain.
228 R hinolog y and Facial Plastic Surgery
DIAGNOSIS AND MANAGEMENT OF FACIAL PAIN
Mid-Facial Segment Pain (Paroxysmal or Continuous)
Mid-facial segment pain is a type of tension headache that aects the mid-face (Figure 45.1b),
and is common. Pain is usually continuous and bilateral. Analgesia overuse is common and
nasal surgery relieves pain for several months only. Tension pain and its management have
been described above.
Persistent Idiopathic Facial Pain (Atypical Facial Pain)
A diagnosis of exclusion only, persistent idiopathic facial pain is described as a persistent
facial pain that does not have the classical characteristics of cranial neuralgias and for which
there is no obvious cause. Signicant psychological disturbance may exist with the suggestion they are unable to function normally because of their pain. Reassure the patient that
you recognise they have genuine pain. Drug treatment revolves around a gradual buildup to
the higher analgesic and antidepressant levels of amitriptyline (75–100mg) at night. Secondline treatment includes gabapentin and carbamazepine. Referral to a clinical psychologist or
psychiatrist may be helpful.
Other types of facial pain are summarised in Table 45.2.
History Taking in Facial Pain
Where is the pain and does it radiate?
•
Bilateral pain is commonly mid-facial segment pain. Migraine, cluster and other trigeminal autonomic headaches, and temporomandibular joint (TMJ) disorders tend
to be unilateral.
Is it continuous or intermittent?
•
Sinogenic pain and migraine are unlikely to be continuous or present on a daily basis.
Pain of this character is more likely to represent tension headache, mid-facial segment
pain, analgesia-dependency headache or atypical facial pain. Constant and predominantly unilateral pain, particularly if progressive, may be due to a tumour.
Table 45.2 Other types of facial pain
Painful teeth TMJ disorder
Location Affected tooth Periauricular areas,
deep otalgia,
temporoparietal and
cervical scalp
Duration Paroxysmal or
continuous
Quality Sharp, well-
localised pain
Other Percussing the
offending
tooth is often
diagnostic
Paroxysmal or
continuous
Aching pain worse
when chewing with/
without clicking,
grinding noises when
moving jaw
Treatment includes joint
rest, NSAIDs,
correction of factors
(e.g. Custom-made
bite guard),
physiotherapy, steroid/
local anesthetic TMJ
injection
Analgesiadependency
headache or
Tumourrelated pain
Unilateral,
dependent on
tumour
location
Continuous or
progressive
Dull or gnawing
pain
Imaging is
crucial
Rhinology and Facial Plastic Surgery 229
medication-overuse
headache
Bilateral, symmetrical
Continuous
Dull, diffuse and
band-like headaches
On stopping analgesics,
headaches disappear
or decrease by more
than 50% in
two-thirds of patients
PRE-ASSESSMENT FOR RHINOPLASTY
What is the character?
•
Vascular pain tends to be throbbing, with cluster headaches being particularly severe.
Mid-facial segment pain, like tension headache, is oen described as pressure or
bandlike pain. Trigeminal neuralgia may cause intense stabbing pain that is initiated
by a trigger.
What is associated with it?
•
Sinogenic pain is associated with adverse rhinological symptoms but should be differentiated from trigeminal autonomic symptoms. Migraine may have aura and is
oen associated with nausea. Cluster headaches are frequently triggered by alcohol
and wake the patient. TMJ pain is exacerbated by chewing, and that of trigeminal
neuralgia and myofascial pain is provoked by trigger points.
What relieves it?
•
Sinogenic pain almost always responds to topical decongestion and antibiotics.
Patients with migraine will retreat to a quiet and darkened room. Although midfacial segment pain may initially respond to simple analgesics, the benet is usually
short-lived.
What eect does it have on daily life?
•
Patients with persistent idiopathic facial pain oen describe their pain in dramatic
detail as severe and unrelenting despite sleeping well and living a relatively normal life.
Severe crippling pain that wakes the patient, oen a man, is typical of cluster headache.
KEY POINTS
• Comprehensive history is mandatory.
• Normal endoscopy in a symptomatic patient makes sinogenic pain extremely unlikely.
• Psychological illness may exacerbate facial pain.
• Surgery for facial pain is rarely benecial.
• Rhinosinusitis does not usually cause pain.
• Incidental mucosal thickening on computed tomography (CT) does not automatically
equate to a sinogenic cause for facial pain.
• Many headache disorders may have associated trigeminal autonomic symptoms.
• Many patients with chronic facial pain benet from neuropathic pain management.
• Multidisciplinary management is helpful.
46. PRE-ASSESSMENT FOR RHINOPLASTY
Rhinoplasty is one of the most challenging procedures in facial plastic surgery and consideration must be given to both facial aesthetics and nasal function. It is technically dicult
to achieve consistently excellent results and, as the surgery is on the most prominent part of
the face, the aesthetic outcome is visible to all. Meticulous planning is therefore essential.
Assessment should include:
Consideration of the patient’s motivations, anxieties and expectations
•
Analysis of the face
•
Analysis of the nose
•
Examination
•
Photography
•
230 R hinolog y and Facial Plastic Surgery
PRE-ASSESSMENT FOR RHINOPLASTY
The Patient
It is essential to obtain a clear history of the patient’s complaint and symptoms. Identication
of any structural, congenital, traumatic, cosmetic and/or functional issues is crucial. Any
past history of nasal surgery, sinonasal disease, diabetes, psychopathology, anticoagulant
medication, smoking or cocaine use should be elicited. It is important to understand the
patient’s motivations, anxieties and expectations.
Identifying High-Risk Patients
High-risk patients are un likely to be satised with su rgical results. Examples are patients with
body dysmorphic disorder (BDD), those who are unreasonably demanding or overly attering, patients who insist on secrecy and the so-called surgiholic, as well as obsessive, perfectionist and impolite patients. e simplied acronyms SIMON (single, immature, male,
overly expectant/obsessive, narcissistic) and SYLVIA (secure, young, listens, verbal, intelligent, attractive) describe some of characteristics of the high-risk and the ideal patient,
respectively.
Body Dysmorphic Disorder
BDD describes an altered perception of one’s own appearance that results in distress. It is a
subjective feeling of ugliness or physical defect which the patient feels is noticeable to others,
although the appearance is within normal limits.
ree questions to ask patients, based on the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) criteria, have been developed to help surgeons screen for BDD:
1 Are you worried about your appearance in any way?
2 Does this concern or preoccupy you? at is, do you think about it a lot and wish you
could worry about it less?
3 What eect has this preoccupation with your appearance had on your life?
Expectations
Determining pre-operative expectations is crucial as poor results are oen based on emotional dissatisfaction rather than technical failure. It is therefore important to ask the
following:
What are your outcome expectations?
•
How do you anticipate your life will be dierent following treatment?
•
What if your expectations are not met?
•
Analysis of the Face
Attractive faces are deemed to have ideal measurements and angles, which are reportedly
based on the dimensions rst described by Leonardo da Vinci.
Facial symmetry is reported to be the basis for a beautiful face, although minor asymmetry
may be associated with the perception of beauty. Many patients are unaware of minor facial
asymmetries and, if they discover these in the post-operative period, it could lead to dissatisfaction and misunderstanding. It is therefore important to raise these concerns with the
patient and document them pre-operatively.
Analysis of facial proportions is performed using the ‘rule of thirds’ and the ‘rule of hs’ to
assess the face from a frontal view (Figure 46.1A). e nose ideally occupies one-third of the
length of the face and one-h of its width. Powell and Humphrey described the ideal angles
of the facial aesthetic triangle (Figure 46.1B).
Facial proportions act as a guide and are helpful in planning procedures but should not be
taken as absolute. Each rhinoplasty should respect the individual’s wishes, gender, ethnicity
and character.
Rhinology and Facial Plastic Surgery 231
PRE-ASSESSMENT FOR RHINOPLASTY
Figure 46.1 (A) The concept of dividing the symmetric face into thirds and fths. (B) Triangles
of Powell and Humphrey. Angles of the aesthetic triangle: nasofrontal (NF) = 115–135, nasofacial
(NFc) = 30–40°, nasomental (NM) = 120 –132° and mentocervical (MC) = 80–95°.
Analysis of the Nose
Inspection of the External Nose
Skin quality: in skin is unforgiving and minor irregularities are easily detectable;
•
rening and narrowing the nasal tip can be challenging where there is thick skin.
Deviations: e nose is divided into thirds. e upper third corresponds to the bony
•
vault, the middle third to the upper lateral cartilages and dorsal septum and the lower
third to the lower lateral cartilages, caudal septum and alar base. Deviated noses
are described on the basis of direction of the deviation of each third, e.g. classically
described C-shaped, one-sided or S-shaped deviations.
Length of the nose: Measured from the nasion to the tip, which is equal to the distance
•
between the stomium and the menton. is can also be calculated mathematically as
the distance from the nasal tip to the stomium multiplied by a constant of 1.6. Nasal
length: NT = TS × 1.6.
Tip projection: is is a measure of how far the nasal tip lies anterior to the face. Ideal
•
projection is determined using Goode’s ratio, where a line drawn from the alar–facial
groove to the nasal tip measures 0.55–0.60 of the distance from the nasion to the nasal
tip. A ratio less than this equates to an under projected nose and greater than this corresponds to over projection (Figure 46.2A).
Lip–chin relationship: e horizontal distance from the surface of the upper lip to that
•
of lower lip is normally around 2 mm. e anterior surfaces of the upper and lower lips
rest on the nasomental line in an aesthetic face (Figure 46.2B). When the chin lies pos-
terior to this line, it is described as retrognathic; when it lies anterior it is prognathic.
A retrognathic chin can give the illusion of an over projected nose, and the reverse
applies to a prognathic chin. Genioplasty or chin implant procedures are therefore
oen used in conjunction with rhinoplasty.
Dorsum: e dorsum is inspected from both frontal and lateral views. Tracing the
•
lateral aesthetic lines (also known as the brow-tip line) should reveal a smooth curvilinear line connecting the eyebrow superiorly to the nasal tip inferiorly (Figure 46.3A).
232 Rhinology and Facial Plastic Surgery
PRE-ASSESSMENT FOR RHINOPLASTY
(A) (B)
N
AT
lip
Upper
lip
Lower
Figure 46.2 (A) Determining tip projection by using Goode’s ratio. (B) Lip–chin relationship.
Identication of any irregularities in this smooth curve highlights sources of nasal
deformity. In the lateral view, the height of the dorsum is assessed; the dorsum is a
straight line in men and in women gently curves with a supratip break delineating the
dorsum from the nasal tip.
Tip conguration: ere are four tip-dening points identied by light reection
•
(Figure 46.3A). ese represent the domes, the supratip and the infratip. e size and
shape of the lower lateral cartilages are assessed, as are asymmetry, bidity and
rotation.
Tip rotation: e ideal dimension of the nasolabial angle in men is 90–95°and in
•
women is 95–105°(Figure 46.3B).
Columellar show: e relationship between the ala and the columella is assessed in
•
the lateral view. e amount of visible caudal septum is ideally limited to 3–5 mm
(Figure 46.3B). is is the distance between two parallel lines drawn from the most
anterior and the most posterior parts of the nasal vestibule. A degree of columellar
show greater than this may be due to either a hanging columella or abnormalities in
the alar margins such notching or retraction.
Basal view: The width of the alar base approximates to the intercanthal distance.
•
The ratio of the width of the dorsum of the nose relative to the alar base should
be equal to 80%. From the basal view, the nose can also be divided into thirds.
The upper third corresponds to the lobule and the lower two-thirds correspond
to the columella. A line that transects the columella at the area of medial crural
footplate diversion divides the base into two halves. The overall basal view outline
conforms to an isosceles triangle with pear-shaped nostrils lying at a 45° angle to
the vertical.
Retrognathia
Prognathia
Inspection of the Internal Nose
Anterior rhinoscopy and nasal endoscopy should be performed.
Septum inspection should be made, looking for deviation, spurs, perforation or the
•
presence of a septal button.
Lateral nasal wall and turbinate inspection can identify congestion, hypertrophy and
•
as ymmet ry.
Rhinology and Facial Plastic Surgery 233
PRE-ASSESSMENT FOR RHINOPLASTY
Nasolabial angle
Men
(i)
Figure 46.3 (A) Front and right oblique views showing the brow-tip line. Note the four tip-dening
points. (B) (i) Nasolabial angle in men and women. (ii) Normal columellar show.
Internal nasal valve assessment should be carried out during normal quiet respira-
•
tion at rest, as exaggerated eortful breathing is likely to precipitate transient internal
nasal valve collapse in the normal individual.
Cottle’s manoeuvre of opening the internal nasal valve by pulling on the so tissues of
•
the cheek is non-specic. A better test is to place a Jobson Horne probe in the internal
nasal valve to prevent the collapse of the upper lateral cartilage and detect its eect on
inspiration.
Alar collapse is a measure of external nasal valve collapse and must be identied
•
pre-operatively.
e external nasal valve is not a true valve and is identied by the area bounded by alar
•
cartilages, septum and columella.
Endoscopy can exclude polyps, purulent discharge or residual adenoidal tissue.
•
234 R hinolog y and Facia l Plastic Surgery
Women
90–95
95–105
Columellar show
3–5 mm
(ii)
RHINOPLASTY FOLLOWING NASAL TRAUMA
Palpation
Skin: Palpate for an assessment of skin texture and elasticity.
•
Irregularities: Palpate for underlying irregularities that may be due to skin, so tissue,
•
cartilage, bone or previous gra material.
Nasal bones: Assess the size, position and presence of palpable steps.
•
Tip recoil: is is an assessment of the strength of the lower third of the nose and pro-
•
vides a palpable measure of the degree of underlying tip support.
Alar cartridges: Palpate for thickness, strength and shape.
•
Spine and septum: Assess tip support, and conrm the presence and quantity of septal
•
cartilage.
Photograph Review
Standardised photographs are essential for pre-operative planning. ey guide preoperative
discussion with the patient, act as an intraoperative reference and are essential for comparison with post-operative results. e standard photographic views obtained for rhinoplasty
are frontal, le and right lateral, le and right oblique and basal.
Computer Imaging
Computer morphing of the pre-operative photographs has been found to enhance communication with the patient. However, it is essential to clarify to the patient that image manipulation is only a means of communication and does not imply a specic guaranteed outcome.
Conclusion
Following the systematic assessment and examination of the patient, the proposed surgery
can be eectively planned with clear surgical steps. It is good practice to commit the surgical
steps to a written plan.
KEY POINTS
• Rhinoplasty is a technically challenging procedure for which both the aesthetics and
the function of the nose must be considered.
• Meticulous planning is essential to ensure the best surgical outcomes.
Successful surgery requires realistic patient expectations, careful consideration of facial
aesthetics and a detailed examination of the nose.
47. RHINOPLASTY FOLLOWING NASAL TRAUMA
Introduction
Forty percent of facial fractures aect the nasal bones, and many of these involve damage to
the nasal septum. External forces that are sucient to cause a bony or cartilaginous deformity can also damage the overlying skin and so-tissue envelope, commonly leading to a
scar or contour abnormality.
A distinction should be made between childhood and adult fractures, as any injury in the
growing nose will likely have consequences for future nasal development. Trauma can, of
course, be superimposed on preexisting deformities, or in a patient who has had a previous
rhinoplasty. In these cases, old photographs indicating pre-injury status are helpful.
Rhinology and Facial Plastic Surgery 235
RHINOPLASTY FOLLOWING NASAL TRAUMA
Assessment
It should be clearly documented whether the primary issue is functional, aesthetic or both. e
assessment and investigation should be carried out in a standardised approach. Firstly, external
examination of each third of the nose is done looking for irregularity, asymmetry, deviation
and skin injury followed by anterior and posterior rhinoscopy. Attention should be paid to the
septum (septal haematoma, and septal displacement) and all levels of the nasal valve. In addition to standard clinical rhinoplasty photographs, a head-down photograph is useful.
Timing of Surgery
Primary Management of Trauma
Management of simple nasal fractures is outlined in Chapter 41.
In cases of an acute saddle nose deformity or complex nasoethmoidal fractures a posttrauma rhinoplasty should be undertaken in the acute or subacute period as septal collapse
is dicult to restore later once scarring and brosis are established.
Lacerations to the skin over a compound fracture need to be closed primarily but may provide access enabling primary reduction of displaced nasal bones.
‘The Missed Opportunity’: Subacute
Where the nasal bony pyramid is displaced but the time from injury has passed that of closed
manipulation, re-opening the partially healed fractures is necessary to remobilise the bony
fragments allowing better realignment.
Post-Trauma Rhinoplasty
General Principles
e key is to create a stable dorsal line connected to the nasal bones, and then correct the
position of the anterior and posterior angles, as these two important points determine the
support of the tip cartilages, nostril shape and the columella–labial prole.
Wide exposure via the external approach with full septal dissection gives the best control to
evaluate the deformity and to reconstruct, mostly with the use of gras, such as local (septal
cartilage), autologous (rib) or allogenic (cadaveric rib).
Rib cartilage can be dicult to use, and choosing the more horizontal sixth or seventh rib
via the inframammary or direct approach gives a straighter gra. e goal is to harvest thin,
stable and non-calcied cartilage gras without signicant warping.
With these gras the septal framework (L-frame) can be repaired or a new L-shaped strut must
be created. e most important xation point of this framework is to the nasal spine (via drill
hole or into periosteally), which should be midline. e dorsal and posterior cartilage needs to
be secured to the residual dorsal septum or axed to the perpendicular plate and nasal bones.
Upper Third
Deformities commonly involve the cartilage as well as the bone (upper laterals and septum).
ese deformities can be very dicult to correct by traditional osteotomies and need a different approach with a more controlled re-opening of the old fracture lines, sculpting and
re-shaping of the bones by ne rasps or, better, by modern power tools or piezosurgery. e
use of securing sutures through the bone and upper septum allows a more satisfactory repositioning than leaving ail segments with little control of how they heal.
Re-sculpting using modern power tools or piezo requires wide undermining via an open septorhinoplasty approach. Collapse or loss of the nasal bone does not occur when the internal
periosteal lining is preserved. A signicant advantage of using the piezo device is that it will
not damage so tissue. Pre-operative computed tomography (CT) facial bone scanning with
three-dimensional (3D) reconstruction allows for more accurate planning.
Final contouring of defects or concavities can be performed with autologous tissue such as
diced cartilage either as a paste, with a fascia wrap (diced cartilage wrapped in fascia [DCF]),
or molded using a physiological glue (e.g. platelet-rich plasma [PRP]).
236 R hinolog y and Facial Plastic Surgery
RHINOPLASTY FOLLOWING NASAL TRAUMA
Middle Third
e middle-third support is important for the form and function of the nose as this is part of
the complex area of the nasal valve.
is area needs to be tensioned between the attachments at the pyriform aperture and the
dorsum to prevent dynamic collapse. e principle aer adequate septal repair is to support
the junctional roof. Spreader gras are the mainstay of treatment here for the damaged nose
and they can be placed according to the aesthetic and functional needs.
For conservation and re-orientation purposes a turn-in ap (spreader ap) can be used as
well. Camouaging techniques to correct the contour may also be considered.
Nasal Tip/Lower Third
Loss of cartilage (mainly septum and lower laterals) can produce multiple deformities in the
tip, commonly with associated so-tissue damage. Loss of tissue volume usually requires
reconstruction with gras, with ear cartilage being a good source.
With an undamaged envelope, tip repair can be achieved by endonasal techniques, but with
a more complex problem, the open approach permits wide exposure, release of contractions
and accurate repair or graing.
Commonly used gras of cartilage are strut or septal extension gras between the medial
crura, shield and cap gras, rim gras for nostril sidewall stability and lateral crural gras,
either to augment or to replace a lost framework.
The Skin Envelope
Probably the most frequently traumatised area is at the rhinion where the skin is thinnest.
Lacerations should be cleaned, dressed or sutured primarily to prevent tattooing. Adequate
sun protection of scars, moisturising, massaging and use of silicone gel daily all contribute
to good cosmetic scar result.
In thin, damaged skin and severe subcutaneous tissue loss, fat graing to the nose can be
considered and camouaging the dorsum skeleton at the time of surgery may be achieved by
using autologous temporalis fascia, perichondrium from rib or rectus abdominis fascia and
PRP and nanofat injections.
Nasal Trauma and Children
Children’s nasal injuries are common and have the potential to disrupt normal growth,
particularly with loss of septal cartilage, as happens with a septal abscess.
In general, it is best to defer surgery at least until aer puberty and as close to maturity
as possible. is deformity increases with age and it can be dicult to resist pressure to
operate early before nasal maturity. e timing is variable between sexes and in individuals. Osteotomies do not disturb growth of the nose but damage to the growth centres in the
septal cartilage does. e patient’s parents need to be warned of a possible second operation
when growth has stopped.
Where a saddle occurs, replacement by autologous cartilage is preferred as continued growth
may then occur.
KEY POINTS
• Childhood injuries need to be monitored to assess growth.
• Acute saddles require early surgical intervention to restore septal height.
• Cartilage-depleted noses may need rib grafts for reconstruction.
• Secondary procedures are common in the repair of damaged noses.
Rhinology and Facial Plastic Surgery 237
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