Учебники / Rhinoplasty Dissection Manual Toriumi 1999

Selected Complications

of Rhinoplasty

Bossae: A knuckling of lower lateral cart ilage at the nasal tip caused by contractural heal­ ing forces acting on weakened cartilages. Patients with thin skin, strong cartil ages, and nasal-tip bifidity are especially at risk . Exce ssive resection of lateral crus and failure to eliminate excessive interdomal width may play some role in bossae formation .

Polly beak: Postoperative fullnes s of the supratip , with an abnormal tip-supratip relation. This has several etiologies: Failure to maintain adequate tip SUpp0l1 (postoperative loss of tip projection), inadequate cartilaginous hump (anterior sept al angle) removal, and/or supratip dead space/scar formation .

Treatment depends on anatomic cau se. If the cartilaginous hump was underresected, then resect additional dorsal septum. One also must ensure adequate tip support. Ma­ neuvers such as placement of a columellar strut may be of benefit. If the bony hump was overresected, consider a graft to augment the bony dorsum. If a polly-beak is from ex­ cessive scar formation , consider triamcinolone (Kenalog) injection or skin taping in the early postoperative period, before any consideration of surgical revision.

Inverted V deformity: Inadequate support of the upper lateral cartilages after dor sal-hump remov al can lead to inferomedial collapse of the upper lateral cartilages and an "inverted V deformity." In this deformity, the caudal edges of the nasal bones are visible in broad relief. Inadequate infracture of the nasal bones is also a frequent cause. When executing hump excision, it is helpful to preserve the underlying nasal mucoperichondrium (extra­ mucosal dissection), which provides significant supp ort to the upper lateral cartilages and help s decrease the risk of inferomedial collapse of the upper lateral cartilages after hump excision . When undertaking osteotomies after hump excision, appropriate infra c­ ture and narrowing of the bony vault must be achieved .

Rocker deformity: If osteotomies are taken too high, into the thick frontal bone , the supe­ rior aspect of the osteotomized nasal bone may project or "rock" laterally when the bone is infractured . This is a "rocker" deformity . A 2-mm osteotome may be used percuta­ neously to create a more appropriate superior fracture line and correct the rocker defor­ mity.

Dorsal irregularities: After creation of an "open roof" by hump removal, the bony mar­ gins should be smoothed with a rasp. Any bony fragments should be removed, making sure that all obvious particles are removed from under the skin/soft-tissue envelope. Fail­ ure to remove all fragments may lead to a visible and/or palpable dorsal irregularity.

Nasal valve collapse: The surgeon should recognize the existence of the internal and ex­ ternal nasal valve . The internal nasal valve area is bounded by the caudal margin of the upper lateral cartilage, septum, and floor of the nose. The external nasal valve refers to the area delineated by the cutaneous and skeletal support of the mobile alar wall. Exces­ sive narrowness in either of these locations may cause nasal obstruction . Weakness at ei­ ther of these locations may result in collapse with the negative pressure of inspiration, resulting in nasal airway obstruction . Nasal valve collapse is seen most often as a sequela of overresection of lateral crura or middle vault collapse. Overaggressi ve resection of the lateral crura and the sub sequent postoperative soft-tissue contraction frequently leads to nasal valve compromise .

J.Simons RL, Gallo JF. Rhinoplasty complications. Facial Plas t Surg cu« Nor th Am 1994;2 :52 1-529 .

2.Kamer FM, Pieper PG. Revision rhinoplasty. In: Bailey B, ed. Head an d Ne ck Surge ry Oto laryn Philadelphia: Lippincott, 1998:26632676.

3.Tardy ME, Kron TK, Younger RY, Key M. The cartilaginous pollybeak: etiology, prevention, and tr

Facial Pla st Surg 1989;6:113-1 20.

4. Larrabee WF Jr. Open rhinoplasty and the upper third of the nose. Facial Pla st Surg Clin No rth Am 23-38 .

5. Toriumi DM. Management of the middle nasal vault. Oper Te ch Pl ast Reconstr Surg 1995;2: 16-30.

6.Becker DG, Toriumi DM, Gross CW, Tardy ME. Powered instrumen tation for dorsal nasal reduction Plast Surg 1997; 13:291-297.

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Appendix I:

Cleft Lip Nasal Deformity

UNILATERAL CLEFT (Fig. 3)

Nasal tip:

Medi al crus of LLC shorter on cleft side

Lateral crus of LLC longer on cleft side (total length of cleft and noncleft side LLC are the same)

Tip-defining point on cleft side is flat and laterally displa ced Columella:

Short on cleft side

Columellar base directed to noncleft side (unopposed orb iculari s muscle ) Nostril:

Hori zontal orientation on cleft side Alar base:

Laterally , inferi orly, and post eriorly displaced on cleft side Nasal floor:

Usually absent Septum:

Caudal deflection to noncleft side Posterior deflection to cleft side

BILA TERAL CLEFT

Figure 3. Cleft-lip nasal deform ity. Typical anatomic findings characteristic of unilateral cleft-lip nasal deformities.