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EXTERNAL RHINOPLASTY
48. EXTERNAL RHINOPLASTY
Introduction
e external approach is a valuable part of the armamentarium of the rhinoplasty surgeon,
oering clear exposure of anatomical deformities, easier bimanual sculpturing, precise gra
placement and suturing and excellent teaching opportunities. We present external rhinoplasty principles, anatomy, techniques and extended applications.
Indications
orough pre-operative assessment of nasal deformities is key in approach selection. External
approach indications include:
Extensive revision surgery
•
Severe trauma
•
Elaborate reduction and augmentation
•
Tip deformities or rotation
•
Extreme over projection correction
•
Congenital deformities such as the cle lip nose
•
Extended applications include septal perforation repair, nasal dermoid excision and even as
a hypophysectomy approach.
Principles of External Rhinoplasty
External or open rhinoplasty, also known as the transcolumellar incision or decortication
technique, exposes upper and lower lateral cartilages to the nasofrontal angle, in their undisturbed positions. Correct incision placement and meticulous wound closure is essential. A
mid-columella incision is connected to bilateral marginal incisions. Subsequent subperichondrial and subperiosteal dissection, leaving as much so tissue as possible on the skin
ap, preserves its viability.
Division of medial intercrural tissue and the upper lateral cartilage from the quadrilateral
cartilage exposes the whole septum and premaxillary spine, allowing treatment of nasal
valve problems, dorsal septal deviations and septal perforation repair. e external approach
avoids intercartilaginous incisions, thus preserving the valve area. Some minor tip support
mechanisms are disrupted, including the lower lateral cartilage so tissue envelope and
medial intercrural ligamentous tissue, which can result in some tip ptosis.
Surgical Technique
Incisions
Common transcolumellar incisions include the step, gullwing and preferably an inverted V,
placed above the medial crural footplates, ensuring adequate support and an inconspicuous
scar (Figure 48.1a). An initial supercial columellar incision is made to protect the medial
crura just beneath. Vertical marginal columellar incisions placed 1.5–2 mm inside the vestibule are joined by careful undermining of the columella skin with scissors, against which the
columella incision is completed. e marginal incision is extended until halfway along the
lateral crus, by spreading angled Converse/Walter scissors and cutting overlying so tissue,
hugging the caudal edge. (Figure 48.1b–d).
Dissection of the Soft Tissue Envelope
Subperichondrial domal dissection minimises supratip oedema, a pollybeak deformity
and bleeding complications. Dissection continues laterally to the hinge area, hugging the
lower lateral cartilage, extending cephalically to the scroll area (Fig ure 48.1e). Midline
inter-domal dissection toward the cartilaginous vault avoids a false passage into supercial
238 Rhinology and Facial Plastic Surgery
EXTERNAL RHINOPLASTY
Figure 48.1 External rhinoplasty approach to correct an under projected, asymmetric bulbous
tip. (a) Mid-columella inverted-V incision. (b) Supercial incision made through the columella skin.
(c) Iris scissors placed behind the incision to protect medial crura. (d) Exposure of the medial crura
with development of the columella skin ap. (e) Dissection over the nasal domes with converse scissors. (f) Exposure of the caudal septal cartilage by dissection between medial crura. (g) Columella
strut placed between medial crura. (h) Closure of incision after correction of boxy tip deformity.
musculoaponeurotic system (SMAS) tissue. ick supratip so tissue can be conservatively
thinned, minimising skin vascular compromise.
Dissect the bony pyramid subperiosteally by palpating and incising just above the caudal
nasal bones, preventing separation of the upper lateral cartilage from the bony pyramid.
Septal access by medial crura division is preferable (Fig ure 48.1f ). Alternative options include
a separate hemitransxion or Killian’s incision. A columella strut in a pocket between medial
crura aids tip projection. It extends from 2 mm above the anterior nasal spine to no higher
than the angle between the medial and intermediate crura, to preserve the columella-lobular
(‘double-break’) angle. Temporary xation of medial crura with a needle minimises dome
height asymmetry, while xating with mattress sutures.
Rhinology and Facial Plastic Surgery 239
EXTERNAL RHINOPLASTY
Preliminary closure of the columella incision allows nal assessment of the supratip area
and tip projection, enabling reduction of the cartilage vault or addition of tip onlay or shield
gras (Figure 48.1g). Check overlying so tissue viability, to prevent skin necrosis.
Incision Closure
Meticulous closure ensures a smooth columella skin line (Figure 48.1h) We prefer a ne
absorbable or non-absorbable suture material (6-0 Ethilon, Vicryl Rapide or Prolene), with
slight ever sion of wound edges. Non-diss olvable sutures are removed 5 –7 days postoperatively.
Specic Applications
The Bony Pyramid
Subperiosteal dissection extends halfway along the nasal bones before bony de-humping and
lateral, medial and intermediate osteotomies. e open approach allows direct correction of
dorsal irregularities.
The Middle Nasal Vault
e internal valve is the smallest area of the nasal airway, bounded by the caudal end of the
upper lateral cartilage, inferior turbinate, oor of the nose and septum. In patients with short
nasal bones, high bony cartilaginous humps or weak upper lateral cartilages, spreader gras
broaden the valve and prevent a ‘pinched’ middle third. External rhinoplasty facilitates
spreader gra xation, roof reconstruction and straightening a dorsally deviated septum.
Nasal Tip
Open rhinoplasty exposes the tip in its natural position, facilitating cartilage manipulation
and gra xation. Manipulating the tripod legs (two lateral crura and conjoined medial
crura), alters tip projection and rotation. For example, the lateral crural steal enhances tip
projection by freeing and medialising the lateral crus from the vestibule skin. Vertical dome
division increases the central leg of the tripod, whereas inter-domal sutures can help correct
a bid tip. Other techniques include the columella strut and tongue in groove.
e open approach facilitates tip deprojection, through precise excision of septal cartilage
and anterior spine. Techniques include lower lateral cartilage lateral crus volume reduction
(complete strip), a complete transxion incision (separating the paired medial crura from
the caudal spine), complete strip procedure and reducing the nasal septum.
Revision Rhinoplasty
External rhinoplasty facilitates precise diagnosis, structural graing and scar tissue excision.
Indications include inadequate or overzealous primary surgery, loss of contour and support.
The Deviated Nose
External rhinoplasty aids bony hump removal in the deviated nose, allowing alteration of the
osteotome plane under direct vision. For right-sided deviation, mobilise the le nasal bone,
then the bony septum and nally the right nasal bone.
Deviation of the lower two-thirds following septoplasty is oen due to dorsal septal deviation and by previously disrupting the septal-upper lateral join. Where mild, shave the convex
side, suture to upper laterals and crosshatch the concavity. If severe, a unilateral spreader
gra opens the nasal valve, with an onlay gra for residual deviation.
The Tension Nose
Quadrilateral nasal septal overgrowth causes a ‘tension nose’ with a high nasal dorsum, narrow vault, long anterior nasal spine and stretched overlying skin. Lower lateral cartilages are
pushed forward and downward, blunting the nasolabial angle and shortening the upper lip.
Extended Applications
e external approach facilitates large septal perforation repair by exposing the entire septum
and excision of nasal dermoids by avoiding poor cosmesis associated with a vertical midline scar.
240 R hinolog y and Facial Plastic Surgery
COSMETIC FACIAL INTERVENTIONS
Conclusions
e external approach is essential for the rhinoplasty surgeon, enabling binocular vision,
bimanual manipulation and gra xation. Precise columella incision, correct dissection
and meticulous suturing minimises sequelae, such as prolonged supratip oedema and pronounced transcolumellar scars. Relative disadvantages of increased operating time and difculty of dorsal assessment are minor and improve with surgical experience.
KEY POINTS
• External rhinoplasty provides unparalleled nasal skeleton exposure, enhanced diagnosis
and correction of deformities.
• It is valuable in tip surgery and for precise placement of grafts and sutures
• Reconstitution of tip support with a columellar strut is often required.
• The broken transcolumellar incision gives excellent cosmesis.
49. COSMETIC FACIAL INTERVENTIONS
Blepharoplasty
e term blepharoplasty refers to the modication of the eyelid aesthetics, while maintaining function. Tissues including the skin, orbicularis oculi muscle, septum and fat are variably are excised or repositioned depending on the anatomical defects and desired aesthetic
outcome. e indications may be functional, aesthetic or oen a combination of both.
In the upper lid skin excess (dermatochalasis), in the early stages it obliterates the natural skin
crease, and when advanced results in visual eld defects (peripheral in particular) as well as
aesthetic changes. In the lower eyelid generally, the aesthetic concerns relate to fat prolapse,
resulting in bags under the eyes and elongation of the eyelids, imparting tired a look.
ese changes are related to aging with laxity of the periorbital ligaments and skin leading
to skin redundancy, changes in the orbicularis muscle (both attenuation and hypertrophy),
as well as weakening of the orbital septum that is responsible for holding orbital fat in its
anatomical locations. A thorough understanding of the surgical anatomy of the eyebrows,
eyelids and mid-face is essential prior to performing a blepharoplasty.
Pre-operative planning should include accurate documentation of patient concerns, medical
photographs, a complete ophthalmic assessment and a plan to dene and alleviate the anatomical cause of the eyelid abnormality, and an informed discussion. Any additional procedures that may be required such as repositioning of the lacrimal gland, correcting the brow
ptosis and lateral canthal procedures should be discussed. Surgery may be carried out under
local anaesthetic with sedation or general anaesthetic.
Important surgical references for upper eyelid blepharoplasty include (Figure 49.1):
Any eyelid ptosis or brow ptosis should be addressed.
•
A minimum distance of 7–8 mm should be le between lid margin and the upper
•
eyelid skin crease and approximately 22–25 mm of skin between the inferior aspect of
the eyebrow and the eyelid margin.
e upper eyelid skin crease represents the most superior point of attachment between
•
the skin and the levator aponeurosis. is position is just inferior to the insertion of
Rhinology and Facial Plastic Surgery 241
COSMETIC FACIAL INTERVENTIONS
Medial (nasal)
in
12-15mm
fat pad area
7-8mm
Figure 49.1 Upper lid blepharoplasty surgical markings. A minimum distance of 7–8mm should
be left between lid margin and the upper eyelid skin crease; 12–15mm should be left between the
inferior aspect of the eyebrow and the upper eyelid skin crease.
Lacrimal
gland area
Area of sk
excision
the orbital septum onto the levator aponeurosis. e skin crease lies at a higher level in
females, approximately 7–8 mm from the lash line, compared with 5–6 mm in males.
It is important not to raise the skin crease in males to avoid a ‘feminisation’ of the
eyelid appearance.
In general, the removal of fat from the upper eyelid should be avoided or restricted to the
medial fat compartment to prevent ‘hollowing’ of the eyelid that post-operatively manifests a
‘cadaveric’ appearance, which is not easily amenable to correction. Other anomalies include
a prolapsed lacrimal gland, which can be repositioned by suturing the capsule of the lacrimal
gland to the inner aspect of the periosteum of the lacrimal fossa. Rare anomalies such as a
prominent supra-orbital rim can be reduced by drilling.
In the lower eyelid the focus is on either excision or re-draping of the prolapsed fat, tightening the orbital septum and, rarely, skin excision in the lateral aspect of the lower eyelid,
which is kept to the minimum.
It is important to recognise when a blepharoplasty is inappropriate. is includes risk factors that expose a patient to exposure keratopathy, namely a history of contact lens wear,
previous corneal laser refractive surgery, dry eye, facial palsy or thyroid dysfunction (which
causes thickening of the subcutaneous region). Postmenopausal women should be specically warned of the temporary risk of dry eyes immediately post-operatively (which may last
weeks). Serious complications include orbital hemorrhage (0.05%) or a retrobulbar hematoma, which may present as severe pain, and result in disrupted cosmesis and/or blindness
(which is a surgical emergency).
Non-surgical interventions, such as a chemical brow li using botulinum toxin in the glabellar area and lateral/superolateral orbital rim, may achieve a 3-mm li.
Surgical Rejuvenation of the Aging Face
A rhytidectomy (faceli) is an operation that corrects the visible signs of aging primarily in
the lower two-thirds of the face and upper neck. is includes redundant facial skin and deep
rhytids, jowling or loss of a well-dened mandibular border and improvement of prominent
nasolabial folds. Extrinsic aging derives mainly from solar ultraviolet radiation (photoaging), which damages the DNA, and smoking. Skeletal deation results in poor ligamentous
support, resulting in tissue sagging exaggerated by gravity.
Patients should be counselled that rhytidectomy is not eective for supercial rhytids resulting
from solar damage or minor depressions secondary to acne scarring. Adjunctive techniques,
such as laser resurfacing/dermabrasion/radiofrequency/platelet-rich plasma (PRP) therapy are
indicated. A healthy lifestyle should be advocated to maintain the results in the long term.
242 R hinology and Facial Plastic Surgery
COSMETIC FACIAL INTERVENTIONS
or SMAS manipulation
mandible
SMAS entery point f
Area of skin ap elevation
NLF/submandibular gland/jowls
Skin incision
Angle of
Figure 49.2 Rhytidectomy surgical principles including the skin incision, area of skin ap eleva-
tion and elevation of SMAS ap below the zygomatic arch (ensuring that the frontal, marginal and
greater auricular and buccal nerves are protected), SMAS manipulation (plication, imbrication, or
combination of techniques) and skin re-draping without tension on the suture lines.
e major limitation of faceli surgery is related to the sagging of tissues in the submental
area, and prominence of the submandibular glands.
Good surgical candidates are those who have a strong bony architecture dened by a welldened mandible and high hyoid, with good facial so tissue volume, and skin elasticity.
Pre-operatively, evaluate the patient’s skin type (Glogau classication) and note any signicant skin pathology. Beware supplements such as vitamin E, Ginkgo biloba and garlic can
also increase bleeding. Patients must stop smoking cigarettes 3–4 weeks before surgery to
avoid vascular compromise, necrosis of skin aps and skin sloughing post-rhytidectomy.
Pre-operative photographs are essential to aid planning, and medicolegal defence, with standardised full-face frontal, lateral and oblique views.
e surgical principles of rhytidectomy include (Figure 49.2):
Incision placement is critical to help hide incisions and avoid altering the hairline.
•
Post-tragal faceli incision (most female patients).
•
Pre-tragal incision (males).
•
Patient should be marked pre-operatively including incision, area of jowling, submandibular
bulge, nasolabial folds, platysmal banding, surface anatomy of greater auricular and frontal
and marginal mandibular nerves.
Inadequate volume in the face may be addressed by autologous fat transfer intra-operatively,
and with careful planning neck fat may be transferred. Alternatively, fat from of other areas
of the body may be harvested. Other options include injections of appropriate llers.
e surgical steps include:
Inltration with local anaesthetic.
•
Elevation of the skin ap.
•
Elevation of the supercial musculoaponeurotic system (SMAS) ap, ensuring that
•
the frontal, marginal and greater auricular and buccal nerves are protected.
SMAS manipulation (plication, imbrication or combination of techniques).
•
Skin re-draping without tension on the suture lines.
•
Rhinology and Facial Plastic Surgery 243
COSMETIC FACIAL INTERVENTIONS
If there is signicant submental laxity, a midline platysmaplasty is performed.
•
Liposuction is restricted to the neck and along the lower border of the mandible ensur-
•
ing any fat in the face is preserved.
Closure may include surgical drains, use of brin glue (under the skin ap) or other
•
techniques to minimise bleeding.
A full bandage is applied covering the head and the neck.
•
Complications include:
Bleeding.
•
Haematoma formation (incidence 4%):
•
Small, non-expanding haematomas aer 24 hours may be amenable to aspiration
•
or drainage (by opening the existing incision), followed by a pressure dressing.
Expanding haematoma constitutes a surgical emergency, requiring immediate
•
wound exploration and clot evaluation.
Temporary nerve paralysis.
•
Permanent nerve paralysis (rare, 0.1%): the most injured nerve is the great auricular
•
nerve, followed by the marginal, buccal and frontal nerves.
Pixie ear deformity results from improper incision placement around the lobule and/
•
or tension in the suture line because of overzealous skin ap excision, which can be
avoided by preventing any excess tension on the lobule.
Patients should be advised of the expected post-operative discourse in which pain becomes
more intense aer 24 hours but settles within 72 hours. Oedema resolves over several weeks
and facial contour stabilises at approximately 4–6 weeks aer surgery. Erythema of the incision should fade over several months.
Non-Surgical Rejuvenation of the Aging Face
Non-surgical rejuvenation is gaining popularity because of minimal downtime, less expense
and acceptable results. ough the eld of anti-aging and facial rejuvenation is advancing
rapidly with new information and new therapies, the basic principles remain the same. ese
include skin care with pharmaceutical and cosmeceuticals used on a daily basis; periodic use
of Botulin toxins and llers; and in some cases more invasive treatments such as chemical
peels, heat technology (such as laser, radiofrequency or their variations) and plasma therapy.
As new technologies evolve, our goal should be focused on the patient, honesty and achieving a balanced look, which may be part of an overall programme of health and self-improvement. Oen this is achieved by a combination of tools.
Prescription topical retinoids form the cornerstone of any topical rejuvenation plan. ey
act on retinoic acid receptors (RARs) and the retinoid X receptors (RXRs), which are receptors found in all cells, targeting keratinocytes and melanocytes in the epidermis and broblasts in the dermis. is leads to epidermal hyperplasia and impaction of the stratum
corneum (producing smoother skin with a ‘glow’); increased dermal collagen type I, III and
VII synthesis; reduced collagen breakdown and normalisation of elastic tissue organisation (improving coarse wrinkling and crepe-like skin texture) and a reduction in melanin
synthesis.
Tretinoin and retinaldehyde are the most studied agents. Retinaldehyde is a precursor that
is oxidised into the active product retinoic acid (tretinoin commercially). Tretinoin is more
irritating, but more eective than retinaldehyde, although large-scale randomised controlled
trials (RCTs) are lacking. e rate of this conversion is variable, making it dicult to calibrate
the concentration of retinaldehyde required to get the best outcome. us, many aesthetic
practitioners use tretinoin rather than retinaldehyde in clinical practice. e senior author
prescribing regimen starts with 0.025%, building up to 0.1% used at varying intervals. e dose
is titrated relative to results versus side eects of the patient. Aesthetic patients generally want
results and do tolerate the short-term side eects, learning to nd their ‘optimal’ dose.
244 Rhinology and Facial Plastic Surgery
COSMETIC FACIAL INTERVENTIONS
Botulinum toxin type A (BTX-A) is a zinc-dependent endopeptidase produced by
Clostridium botulinum. It acts on cholinergic nerve endings to produce muscle paresis that
lasts for around 3 months, and then starts to wear o. When the muscle relaxes, it stops pulling on the skin and the wrinkle caused by the muscle pull fades away. Botulinum toxin has
been the most revolutionary anti-aging treatment in recent years. It has an excellent safety
prole and has been used extensively for facial rejuvenation with a focus on hyperkinetic
wrinkles. It is also used in the dysfunctional paralyzed face to improve facial symmetry or
in the scarred face to improve dermal contour with the use of llers. Generally, an appropriate amount of Botulinum toxin is injected and the patient is reviewed aer 2 weeks for
further injections if required. is helps to avoid creating an unnatural appearance and a
frozen face. Botulinum toxin is contraindicated in patients with underlying neuromuscular junction disorder, allergy to any of its components (human albumin, botulinum toxin),
pregnancy and breastfeeding.
Fillers represent products that are inserted into dierent skin layers to improve angles,
lines, folds, scars and accidity. e idea is to replace an original volume lost by the aging
process or to create volume. Fillers can be temporary or permanent. Although hyaluronic
acid is safe, it binds up to one thousand times its weight in water forming a viscous quality similar to ‘jelly’ that causes an overinated look. e newer generation biodegradable
polycaprolactone-based collagen stimulators restore volume and redene contours in
a more natural way. Severe but rare complications of llers include undesired aesthetic
result, skin necrosis and blindness (which is a surgical emergency). ese should be mentioned in the consenting process. Generally, we recommend avoiding the use of permanent
llers, which have additional complications of long-term damage, inammation, infection
and extrusion.
Chemical peeling is the topical application of chemical agents to cause controlled destruction of part or all the epidermis, with or without dermal injury. is leads to desquamation,
liquefaction and coagulation of the aected layers, followed by inammation, and nally
regeneration of epidermal and dermal tissues. Indications for chemical peeling include ne
lines and wrinkles, pigmentation disorders such as solar lentigines and melasma, supercial
acne scars and benign epidermal growths.
KEY POINTS
• Thorough understanding of the surgical anatomy is essential prior to performing a
blepharoplasty:
• Distance between the inferior aspect of eyebrow and the upper lid skin crease on
downgaze is two-thirds the distance from the inferior aspect of the eyebrow to
eyelid margin.
• Minimum of 10–12mm should be left between the inferior aspect of the eyebrow
and the upper eyelid skin crease in upper lid blepharoplasty.
• Whitnall’s ligament supports the levator muscle complex, hence damage must be
prevented.
• Sun damage to the skin, atrophy of tissues and the effects of gravity bring on the
changes seen in the aging face patient.
• Facial fat injection is a valuable adjunct to aging face surgery, facial.
• Tretinoin has been shown to be most effective in photographing. Its irritational side
effects are reduced by starting a regimen at lower doses and building up to higher
doses at varying intervals.
• Newer generation polycaprolactone-based collagen stimulators restore volume and
redene contours in a more natural way.
• Regenerative surgical techniques may enhance graft survival and improve the quality
of damaged skin.
Rhinology and Facial Plastic Surgery 245
SECTION
3
HEAD AND NECK
50. SURGICAL ANATOMY OF THE NECK
Embryology
Branchial Arches
e branchial arches emerge at the fourth week of gestation. Each arch has its own nerve,
cartilage and artery. e h arch obliterates aer all the branchial arches become apparent.
Between the arches sit internal pouches (lined with endoderm) and external cles (lined
with ectoderm).
Fascia: Anatomy
e neck has supercial and deep fascial planes encasing the structures of the neck. e
supercial fascia invests the platysma muscle.
e investing layer of deep fascia forms a cylinder draping most of the structures of the neck.
It encloses the sternocleidomastoid, omohyoid, infrahyoid and trapezius muscles, and the
parotid gland.
e carotid sheath encloses the common carotid artery, the internal and external carotid
arteries, the internal jugular vein and the vagus nerve.
e pretracheal layer has two parts: the muscular encasing the infrahyoid muscles and the
visceral containing the trachea, the thyroid gland, the pharynx and upper oesophagus.
e prevertebral fascia encompasses the posterior neck muscles, the scalenes and the vertebrae. e alar fascia is a layer of fascia anterior to the prevertebral fascia, extending from the
skull base to level of second thoracic vertebra.
Neck Spaces
Compartments lie between the fascial layers, normally containing loose areolar tissue only.
e submandibular, parapharyngeal and retropharyngeal spaces are described further, other
spaces include the submental, peritonsillar, prevertebral, carotid, parotid and visceral.
Submandibular Space
e superior limit is the mucosa of the oor of the mouth, the inferior is the investing
fascia from the mandible to the hyoid. e anterior and posterior bellies of the digastric
muscle form the anteroinferior and posteroinferior boundaries. e mylohyoid muscle
divides it into superior and inferior compartments, which communicate around the posterior edge.
Head and Neck 247
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