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Rhinoplasty

last modified on: Mon, 05/20/2024 - 08:22

return to: Open Septorhinoplasty - Surgical Demonstration (rhinoplasty) and Cosmetic Facial Surgery

see: Rhinoplasty Case Examples

Note: last updated before 2015

Dr. Douglas Henstrom, University of Iowa Facial Plastic and Reconstructive Surgeon
For appointment please call: 319-356-3600

INCISIONS/APPROACHES/GRAFTS

A. Incisions

  • Hemi-transfixion-through one side of septum only, used to access septum
  • Complete transfixion-incision completely through membranous septum, allows easier access to both sides of anterior cartilaginous septum
  • Transcartilaginous-placed through the cephalic extent of lower lateral cartilage to access dorsum
  • Intercartilaginous-placed between upper and lower lateral cartilages to access dorsum
  • Marginal (infracartilaginous)-at caudal end of lower lateral cartilage
  • Trans columellar (with extended marginal)-combined with marginal in external rhinoplasty
  • Rim-stab incision inside nasal rim for placement of rim grafts

B. Approaches to the Tip

  1. Nondelivery Incisions
    • Transcartilaginous (or)
    • Intercartilaginous (Technique: cephalic resection of the lateral crus. Complete strip = lower lateral cartilage maintains complete continuity)
    • Indications:
      1. Slight tip bulbosity
      2. Minimal tip rotation
  2. Delivery incisions
    • Intercartilaginous (and)
    • Marginal
    • Indications
      1. Moderate bulbosity
      2. Under-rotated tip
      3. Bifidity
      4. Asymmetry
      5. Under/over projection of tip
    • Techniques
      1. Cartilage resection
      2. Scoring and morselization
      3. Alar (domal) suturing
      4. Vertical dome division
  3. External
    • Broken columellar
    • Marginal (with extended marginal)
    • Indications
      1. Congenital deformities (cleft nose)
      2. Extensive revisions
      3. Severe nasal trauma
      4. Elaborate reduction and augmentation
      5. Shield graft placement
      6. Columellar strut
      7. Instructional/Training purposes
    • Techniques
      1. Cartilage resection of lateral and medial crura
      2. Alar cartilage modifications and reorientation
      3. Shield graft placement
      4. Facilitate placement of spreader grafts, columellar struts, alar batten grafts and lateral crural excision, more precise placement of tip suturing

C. Basic Grafting in Rhinoplasty

  1. Shield graft to the tip
    • Can increase projection
    • Increase nasal length (especially if multiple grafts are used)
    • Change in angle of the infra tip lobule (double break)
    • Important: remember to bevel the edges of graft
    • Secure the graft with sutures (we use 5-0 PDS)
  2. Spreader graft
    1. Size: approximately 10-15 mm in length x 2 mm in vertical height x 1-3 mm in width
    2. Placement: between the dorsal aspect of the nasal septum and the upper lateral cartilages
    3. Uses: 
      1. Open the nasal valve (especially in cases of previous over-resection of the vertical height of the upper lateral cartilages 
      2. Widens the middle third of the nose, the upper third to a lesser extent (most patients do not notice or at least do not complain of this side effect)
    4. Correction of a unilateral middle third concavity.
    5. May prevent future middle vault collapse. (Longterm possible complication of osteotomies--Inverted V deformity)
  3. Columellar strut graft
    • Provides strength and rigidity to the medial crura
    • Added structural integrity resists forces that could combine to bend the crura
    • Corrects buckled medial crura
    • Performed in most external rhinoplasties (in almost all of our cases)
    • Few drawbacks
    • Grafting material of choice is septal cartilage
    • Remaining intercrural tissue supports the graft cephalically, caudally and inferiorly
    • Suture into position
  4. Alar batten graft
    1. Provides support for the nasal valve. Can help both the external and the internal nasal valve
      1. Anatomy of valves:
      2. External nasal valve: the area delineated by the cutaneous and skeletal support of the mobile alar wall, anterior to the internal nasal valve
        1. Causes of collapse
          1. Usually from over resection of the lateral crura
          2. Over-resection combined with soft tissue contraction
          3. Tests for external nasal valve collapse: Cottle's maneuver
        2. Treatment
          1. Alar batten graft
          2. Excision of vestibular skin
          3. Butterfly graft vs. Nasal flaring suture
          4. Stitch placed from the nasal mucosa to the infraorbital rim (in cases of facial paralysis - fascia lata to nasal base)
      3. Internal nasal valve: the area at the caudal margin of the upper lateral cartilage and the septum
        1. Causes of collapse
          1. Failure to maintain proper height or support of the middle vault can lead to internal valve collapse
        2. Treatment
          1. Spreader grafts
          2. Alar batten grafts may be of some help in some instances
      4. Steps in endonasal alar batten graft placement
        1. Intercartilaginous incision for the alar batten graft placement
        2. Sharp scissors are used to fashion a precise pocket. The graft is placed in pocket. The superior anterior corner of the graft is trimmed off, reducing the chance of fullness and/or visibility and all edges are beveled.

BASIC RHINOPLASTY PROCEDURE

Essential Steps:

  1. Equipment: 2.5x loupes, headlight, own instruments, posted preop photos and plan.
  2. General Anesthesia with appropriate monitoring
    1. Mark nose: ideal dorsal profile line, lateral osteotomies, ideal tip point, transcolumellar incision (apex at narrowest point of columella), any alar base incisions.
    2. Trim vibrissae
  3. Local Anesthesia: a-Tip and columella b-lateral wall c-dorsum/extamucosal tunnels (infraorbital, lateral nasofacial groove, alar base, columella/sill vessels) d-incision lines e-septum (post to ant)
    1. 4% Cocaine on 4 pledgets (4-5 inch x 0.5 inch)-place first and start vasoconstriction. Not used in patients with history of cardiac disease.
    2. 1% Lido with 1/100,000 epi; then prep-wait for 10-15 mins
  4. Septal exposure via hemi or full transfixion incision and extramucosal tunnels
  5. Septal harvest/septoplasty
  6. Open approach using transcolumellar and marginal incisions
  7. Elevation of skin envelope:
    1. Columella to tip exposure-3 point retraction
    2. Alar and dorsal exposure-2 point retraction
  8. Reassess operative plan based on alar, dorsal and septal anatomy.
    1. Tip Diamond (angle-dome-columella break point-dome) from ant view
  9. Incremental hump reduction-Rasp or osteotome:bony; scissors or 11 blade:cartilage +/- inclusion of upper laterals in excision.
    1. Height, width, length
    2. Upper lateral cartilage excision (dorsal width reduction) is usually 33-50% of the dorsal septal excision (dorsal height reduction).
  10. Identify anterior septal angle. If doing spreader grafts, may separate upper lateral cartilages from septum starting here.
  11. Creation of symmetrical alar rim strips-cephalic trim.
    1. Creates rotation, reduces volume of nasal tip and increases the malleability of the cartilage for improved tip shaping.
    2. Minimum of 6mm, ideally 8mm of lower lat preservation. Cut medial to lat.
      1. Initial width is drawn at the widest point of the lateral crura
      2. Medially, the line is tapered to preserve the natural width of the domal notch.
      3. Laterally, the line follows the caudal border of the lateral crura preserving appropriate width.
  12. Caudal septum/Anterior Nasal Spine reduction
    1. Rotate tip by resecting the upper half of caudal septum
    2. Shortening the nose by resecting the lower half of caudal septum
    3. Altering the columellar labial segment by contouring or resecting the ANS, or plumping grafts
    4. Caudal septal relocation (3 principles: 1-caudal septum must be completely released and totally mobile, 2- fixation of the ANS must be rigid, 3- the structural integrity of the caudal septum must not be compromised by incisions or excisions)
  13. With dorsal height/line and caudal edge placed and finalized-can proceed with cartilage grafting.
  14. Graft preparation
    1. Order of importance: spreader, strut, alar rim, battens
  15. Spreader grafts (20-25mm long x 2.5-3.5mm high x 0.5-3.5 wide)-sutured with 4-0 pds
  16. Columellar strut and suture (20mm long x 2.5 mm wide x 1.5mm thick) placed into pocket, the alars are elevated upward and rotated 90 degrees medially. Fixed individually to strut with 25 or 30 gauge needle just below domes. Ensure symmetry. Vertical 5-0 pds placed across the columella which sandwiches the strut between the crura.
  17. Osteotomies
    1. Lateral-to narrow the base bony width of nose at its widest point
      TIP WORK
  18. Tip Sutures
    1. Domal creation suture R & L (95%)-horizontal mattress suture across the domal segment at the domal notch to create convex domal segment next to concave lateral crura
    2. Interdomal suture-controls tip width both at the domes and in the infralobule-a simple vertical suture. Generally placed 2-3 mm back from caudal border of the crura. Remember the “tip diamond” concept-don’t overtighten.
    3. Tip position suture-increase rotation and projection. Between the infralobular mucosa and the anterior dorsal septum-creates supratip set off-continually reassess with skin redraped and don’t over rotate. (4-0 pds on FS2 needle)-tension can be tightened incrementally.
    4. Add-on refinement grafts “Concealers”-preferably resected alar cartilage
      • Transdomal onlay
      • Infralobular “shield” graft (if top edge of graft extends more than 1 mm above edge of domes, then a “cap” graft must be place behind it to provide ridged support)
      • Can additionally use fascia to further camouflage.
  19. Closure
    1. columellar incision with 6-0 simple sutures
    2. marginal incisions with 5-0 plain catgut
    3. transfixion incision-2-3 sutures of 4-0 plain catgut.
  20. Alar base modification (must assess alar width-crease to crease, alar flare-widest point to widest point of ala, intercanthal width)
    1. nostril sill excision to reduce nostril show
    2. alar wedge excision to reduce nostril flare
    3. combined sill/wedge to reduce flare and width. 
  21. Alar rim support grafts-through alar rim stab incision.
  22. Doyle splints and external cast
    1. Doyle splints with ointment-sutured with 4-0 nylon (tubes left in with major septal straightening, removed when min septal straightening performed)
    2. Nasal Tape/cast-Benzoin applied to nose while fingers in medial canthi, 3 short cephalically placed tapes, then 1 medium long one, then long one under nasal tip then 2 medium length tapes down to supratip region. Benzoin on tape, then cast applied.
  23. Patient Postoperative care
    1. Pt to clean incisions 2-3 times daily with H2O2 and apply ointment with a Q-tip.
    2. Do not get cast wet
    3. Sleep with head elevated
    4. Limit Salt intake
    5. Nasal saline spray to nostril 4-6x/day
    6. Cast and sutures removed at 1 week. May consider reapplying tape in office to last for next 3 -5 days.
  24. Note: All steps are considered, but only those steps indicated are actually used.