General

-nose extends caudally from forehead.

-glabella: forehead region immediately superior to nose.

-nasion (or nasofrontal suture): inferior to the glabella.

-nasofrontal angle:

- deepest part of nasal dorsum,

-is several millimetres inferior to nasion.

-rhinion: osteocartilagious junction

-nasal tip: most prominent portion

-supratip dorsum: area immediately superior to tip.

-soft tissue triangles or facets: small concavities on either side of tip defining point & adjacent to

nostril margin. lnferiorty, this merges into the infratip lobule which narrows to become columella. -columella runs inferiorly to join the lip at the columelia-labial junction (nasolabial angle).

Skin Envelope

-skin generally thicker at nasofrontal angle & thins out as it reaches mid-dorsal region of rhinion.

-from rhinion to nasal tip skin becomes thicker again, (with Ý ‘d sebaceous glands)

-thick skin hides imperfections and subtle changes.

-thin skin less margin of error, but better results are possible.

Vascular supply to nasal skin is via:

-subdermal vascular plexus (supplied by dorsal nasal, ant ethmoidal, facial, sup labial, angular a’s)

Lymphatic drainage

-runs from centrally to laterally into the periparotid and submandibular nodes.

-drainage down columella to perioral region is minimal,

\ external rhinoplasty type incisions should not result in tip oedema due to lymphatic stasis.

Nerve sensation

-nasal tip due to paired anterior ethmoidal nerves.

(Nb post-op lack of tip sensation is due to disruption of these nerves).

-upper dorsum supplied by infratrochlear branch.

-lateral nose and columella is supplied by the infraorbital nerve.

Septum

-dorsal and caudal borders provide support for the nose, and should be left undisturbed.

-caudal septum influences appearance of columella

-Framework is

Bony: - ethmoidal plate and vomer

Cartilaginous: - quadrangular cartilage

-Periosteum of bone and perichondrium of cartilage are continuous.

-Periosteum of bony spine,crests&vomer aren’t continuous with perichondrium \ need sharp dissect’n

Tip

Lower lateral (or alar) cartilages

* paired structures forming a cartitaginous arch supporting nasal lobule and nostrils.

*Divided into:

Medial crus - held together by ligamentous tissue in columelia,

- orientated in saggital plane (often some flaring in most caudal portion).

- medial crural footplate: most poster pt of med crura.

Central crura (or Intermediate crus) - often seen externally as the columella double break.

Lateral crus - flares posterosup’ly away from nasal rim to connect with accessory cartilages . The tip-defining point marks the junction between the central and lateral crura

*NB: Cephalic border of LLC hinges with upper lateral cartilage

Dome - Junction of medial and lateral crura

NB:-Two point tip is aesthetically pleasing

-Tent deformity: single tip point secondary to overtight suture or tip graft poorly placed.

Sesamoid bone: - Accessory cartilage between lateral crura and pyriform aperture

Tip support - nasal tip has been described as a tripod

Þ lateral crura representing two legs and the conjoined medial crura a third.

1. Major tip support

Medial and lateral crura

Attachment of medial crural footplate to quadrangular cartilage

Attachment of the upper lateral cartilage to the alar cartilage

2. Minor tip support

Dorsal cartilaginous septum

Interdomal ligament

Membranous septum

Nasal spine

Surrounding skin and soft tissue

Alar sidewalls

Mid-nose

Upper lateral cartilage...Triangle with:

- base at septum (attached medially)

- apex at pyriform.

- upper portion is under the nasal bones (for about 1 cm), & is held by ligamentous fibers

Septum broadens to form platform

Intranasal valve - Junction of caudal upper lateral cartilage with septum

-Ligaments connect laterally to pyriform to hold valve open

(these may be damaged in rhinoplasty, Þ nasal obstructions)

Support of septal platform via intercartilagious ligaments & lateral ligaments

Polly beak (ie fullness above the tip)

may be due to;

-inadequate cartilage (ULC, LLC) removal in mid-nose or too much tip drop

-excessive bone hump removal, tip ptosis, scar tissue, thick skin

Bony Vault

Paired nasal bones

Midline suture

Thick and strong at superior root

NB - don't need to extend osteotomies this far may Þ 'rocker deformity'

Frontal process of maxilla

Thicker than nasal bones

Osteotomies must extend into these to narrow nose

Nasal spine of frontal bone

Medial support

Thick and strong

PREOPERATIVE PATIENT ASSESSMENT

I. Patient selection and psychological factors

-need to diagnose possibilities/limitations in each patient as an absolute prerequisite to achieving

outstanding results.

-Pts with relatively minimal deformities (small hump,minimally bulbous tip,slightly overwide nose)

almost always are best candidates for near-perfect surgical results.

- More dramatic surgical results are possible in pts with significant deformities (large hump; twisted/

elongated, drooping nose)

-Tardy identifies the following as patients who need more evaluation prior to surgery:

The patient with unrealistic expectations

The obsessive-compulsive, perfectionist patient

The sudden whim patients

The indecisive patient

The rude patient

The overflattering patient

The overly familiar patient

The unkempt patient

The patient with minimal or imagined deformity

The careless or poor historian

The 'VIP' patient

The uncooperative patient

The overly talkative patient

The surgeon shopper

The depressed patient

The plastic 'surgiholic'

The price haggler

The patient involved in litigation

The patient whom you or your staff dislikes

-Management of the dissatisfied patient

Listen attentively

Secondary procedure with the same enthusiasm as the initial procedure

Return visits - Don't abandon them

II Examination

1.Facial asymmetry and overall facial appearance

-facial asymmetries (which are present more often than not)

-overall width of the middle and upper thirds of the nose,

-relationship of the nose to the remainder of the facial features and landmarks

-nasofrontal and nasolabial angles,

-relationship of the chin projection to the nose should be documented

2.External nose

a. Skin quality:

-Evaluate by inspectn/palptn (rolling skin over nasal skeleton & pinching it b/w examining fingers)

- is an essential indicator of the surgical outcome \ plays significant role in preoperative planning.

-thick skin, rich in sebaceous glands and subcutaneous tissue, worst skin type for good result.

nb: Care not to overreduce bony-cartilaginous skeleton in thick-skinned patients in an

attempt to produce a much smaller nose. Failure of thick skin to contract favorably

Þ excess soft-tissue scar, amorphous nasal appearance, and even soft-tissue "polly-beak"

-thin skin, often pale, freckled, and nearly translucent, must be respected.

- ideal for achieving critical definition,(provides little cushion to cover even minor of skeletal irregularities or contour imperfections).

- may develop an undesirable progressive skin retraction over yrs,Þ unnatural/angular nose.

-ideal skin type is between these two extremes.

-has enough s/c tissue to provide a cushion over nasal skeleton but allows critical definition.

b. Lesions, scars

c. Evidence of trauma

d. Alae: shape, size and asymmetry

e. Tip support

Tip recoil

-critical factor in assessing candidate is the inherent strength and support of nasal tip,

-finger depression of tip toward upper lid provides a quick and reliable test

-tip with weak, flail alar cartilages does not tolerate an extensive sacrifice of tissue.

-size, shape, attitude, and resilience of the alar cartilages may be estimated by palpation or

"ballottement" of lateral crus between two fingers surrounding its cephalic and caudal margins.

-alar cartilages must be carefully noted for later correction.

-during this assessment need to decide whether to enhance, reduce, or carefully preserve the tip.

3. Intranasal examination (before and after shrinkage of the mucosa)

-internal vestibule palpation: (with thumb & forefinger surrounding columella)

-columella: width and length.

-medial crura: width and length.

-Short medial crura need supportive cartilage struts to lengthen columella & aid in rotation

-Long medial crura need reduction in width & length +/- retropositioning.

-septal: ?deformity, ? perforation, length & pos’n.

-turbinates

-nasal spine: size, position and its caudal septal angle.

-airway of nasal cavities:

-nasal valves (and their associated upper lateral cartilages)

-septum (as above)

-tip-lip complex: assess its length & its muscle tethering (gives info about potential of tip to rotate)

  III. General medical history and physical examination

1.Hypertension, CAD

2.Anaesthetic history

Previous local sedation- reaction, experience

Allergies

3. Bleeding

Personal and family history

Aspirin, NSAIDS

IV. Discussion of patient's desire, surgical goal, and realistic expectation

Informed consent

Pre-op planning

Simons recommends that every rhinoplasty discussion be performed at least 5 times:

First at initial consultation

Second when pre-op photos are studied

Third when patient is seen again prior to surgery

Fourth when the surgeon operates on the patient

Fifth during long-term follow-up period

V. Photographs

Always!!!

-important guides to operative planning and execution,

-definitive records for evaluation by the surgeon and patient,

-invaluable teaching tools,

-medico-legal records.

VI. Laboratory evaluation

Coags,FBC

NB : Xrays only if nasal and sinus disease is suspected

SURGICAL POINTS

Anesthesia and analgesia

Local anaesthetic versus general anaesthetic

BECKENBERG position (ie head-up or reverse Trendelenburg).

Local is , faster, safer

1. Topical anaesthesia

2. Infiltration anaesthesia

-1% Xylocaine & 1:100, 000 adrenaline

-Incision delayed for 10-15 minutes

-Excellent anaesthesia for 1-2 hours

Monitors (ECG, Oximetry)

IV line

BECKENBURG position (ie head-up or reverse Trendelenburg).

Resusitation equipment

Surgical planes

Within the nose 3 distinct dissection planes can be identified.

1. Extraperiosteal plane:

-Lateral and medial to the ascending process of the maxilla

ie: along the intended course of the lateral osteotomies.

-Infiltration of LA on both sides of ascending process aids in ß bleeding after lat osteotomy

2. Submucoperichondrial and subperiosteal planes of the septum

-Infiltration of LA into this plane Þ hydraulic elevation of septal flap, facilitating elevation and preservation of flap integrity

3. Submucoperichondrial & subperiosteal planes over lower & upper cartilage & nasal bones

-Of greatest importance

-exists just below the subcutaneous tissue layer .

NB:

-Little vascular and neural structures in these planes.

-When anesthetic is injected into these proper planes, it diffuses more readily& requires only

small amounts (usually 3.5-5 ml) to obtain desired anesthetic and vasoconstrictive effects.

Surgical "pen-marks":

-margins of the alar cartilages and their precise tip-defining points,

-the preplanned amount of cephalic reduction required for refinement and definition.

-caudal margins of the nasal bones and maxillary ascending processes

-the estimated extent of the bony-cartilaginous hump removal

-the planned osteotomy pathways may be indicated by dotted lines.

-a plus (+) mark on contour depressions serves to remind of the need for intended augmentation,

SURGERY OF THE NASAL TIP

-rest of nose dimensions are dictated by the tip

-Objectives:

-Construct a stable, properly projecting nasal tip, roughly triangular on base view, which

blends with rest of nasal anatomy

-Cephalic rotation of the tip usually desirable

-Preserve supporting structures of the nose ( to avoid tip ptosis)

-Employ conservative reconstructive techniques

-Philosophy:

-Preserve as many tip supports as possible

-Conserve volume and integrity of lateral crus as much as possible

(ie Employ complete strip techniques before using more risky interrupted strip techiques)

-Tip support mechanisms:

a. major: (1) size, shape, and resiliency of medial and lateral crura;

(2) medial crural foot-plate attachment to caudal quadrangular cartilage

(3) upper lateral cartilage attachment to alar cartilage.

nb: If any or all of these are compromised may Þ "tip ptosis"

b. Minor:

i. Interdomal soft tissue.

ii. dorsal cartilaginous septum

iii. surrounding skin and soft tissues

iv. Alar cartilage attachment to skin and soft tissue.

v. Nasal spine.

vi. Membranous septum.

-Assessment of the need for tip remodeling

Does the volume of the alar cartilage require reduction

Does the alar cartilage require change in attitude or orientation

Does the tip require a change in projection

Does the nasolabial angle ie columellar inclination require changing

Classification of surgical terms

-Incisions are methods of gaining access to underlying supportive structures

-Approaches are procedures either to deliver the tip cartilages or to avoid complete delivery.

-Sculpturing techniques are surgical modifications: excision, reconstruction, or reorientation of alar

cartilages calculated to Þ significant changes in definition, size, orientation, & projection of tip.

-Thus appropriate tip incisions & approaches should aim to preserve as many tip supports as possible.

Incisions Transcartilaginous

Intercartilaginous

Marginal

Approaches Delivery

Nondelivery

Cartilage-splitting

Retrograde

External (open)

Techniques of Volume reduction

Complete strip

Weakened complete strip

Interrupted strip

 A philosophy of a graduated incremental anatomic approach to tip surgery is recommended.

This implies that no routine tip procedure is ever used

Whenever possible a complete strip operation is employed

Nondelivery approaches (cartilage-splitting or retrograde-eversion) approach:

-majority of lateral crus is left intact as complete strip, with resection of only a few mm of med-cephc

portion of lateral crus to effect refinement.

- disturbs very little of the normal anatomy of the tip

Delivery approaches

-for the anatomy more abnormal or asymmetric tip.

-this approach allows direct visual presentation of alar cartilages as bipedicle chondrocutaneous flaps

-greater volume reduction of medial portion of lat crus still maintaining a complete strip > 5 mm wide

-indicated almost exclusively when significant defatting or scar resection is required.

-utilizes intercartilaginous and marginal incisions

 -if necessary, further refinement in tip may be created by weakening the complete strip convexity with

conservative cross-hatching, gentle morselization, or incomplete noncoalescent dome incisions

-patients with extremely thin skin, delicate alar sidewalls, & bulbous cartilage, predictable narrowing

refinement is achieved by transdomal suturing of complete strips with 4-0 nylon horizontal mattress

-Suture passes through both medial and lateral crus on either side and is "test-tightened" before final

securing to ensure proper suture placement and symmetric narrowing.

A modest increase in projection may be realized, if desired, by proper suture placement

-interrupted strip techniques

-indicated in more severe tip deformities, esp when more significant cephalic tip rotat’n is req’d.

-aims to improve tip relationship to face and nose.

-excessive portions of lateral & occasionally med crus are removed, & cartilages are reconstructed

so that their cut ends abut or overlap.

-inherent dangers (asymmetric healing and scarring) exist whenever complete strip is interrupted

-some tip support is almost always lost, which may be compensated by placement of a collum strut

-Open (external) approach:

-indictns: cleft lip, severe nose deformities, severely asymmetric tips

-probs: more operative edema and scarring

-advantages: precise direct-vision diagnosis, bimanual surgery, excellent exposure

Tip projection

-?? need for preservation, enhancement, or reduction of existing tip projection.

-majority of patients undergoing a rhinoplasty have satisfactory projection, \ aim to ensure that major

and minor tip supports are left largely intact (or reconstructed) to prevent loss of projection.

i. Need for preservation Þ Complete strip techniques:

-recommended whenever feasible

-avoid the complete transfixion incision, which destroys the vital support provided by the

medial crural overlap of the caudal septum

ii. Need for enhancement :

-a. Autogenous cartilage struts positioned below and/or between medial crura in crural pocket

 -b. Plumping grafts of cartilage fragments, introduced into base of the columella through a

low lateral columellar incision

-provide an additional platform for the tip projection resulting from the strut.

-should never extend to the apex of the tip skin

-effective in lending support to otherwise weak tip and in effacing acute or retracted

nasolabial angle.

If the medial crural footplates diverge in a widely splayed fashion, further tip projection may be gained by resecting excessive intercrural soft tissue and suturing the medial crura together.

c. Onlay tip cartilage graft

Septal or auricular cartilage

Can alter height and contour

Triangular, trapezoidal or shield-like

SURGERY OF THE CARTILAGINOUS VAULT

-Made up of: dorsal surface of quadrangular cartilage and its related upper lateral cartilages.

-aesthetic goal: -reduction of supratip area to a level that allows the leading edge of tip to exist

1 to 2 mm above the cartilaginous profile.

- male: straight nasal profile with strong, high dorsum

- female: -leading edge of the tip just slightly higher with a gentle slope of 2-3mm

b/w the tip defining point & lower extent of cartilaginous profile

-slightly more open nasolabial profile, accompanied by subtle columellar "double-beak"

-achieved by reversal of usual tip-supratip relationship

(in which the supratip cartilaginous dorsum lies variably higher than the tip)

Philosophy

-Incremental reduction of the cartilaginous septum under direct vision preferred.

-Consider differences in skin thickness - thinner over rhinion, thicker over supratip

"Hump removal" degree and angulation of depend on:

- skin thickness, amount of bony hump relative to cartilaginous hump, relative width of nose,

- inclination of the nasal tip

- surgeon's ability to visualize final appearance of nose after approx 12-18 mnths of healing.

Technique

-Transcartilaginous or intercartilaginous incision:

-continued for 4-6 mm around anterior septal angle - the partial transfixion incision

nb: vital support relationship of med crural attachment to caudal septal margin is preserved

-stay close to perichondrium enveloping upper lateral cartilages & cartilaginous dorsum

to prevent unnecessary trauma to more superficial blood vessels and sensory nerves.

-Access to bony vault is continued by elevation of periosteum over nasal bones with Joseph elevator

exposing entire bony-cartilaginous skeleton (using the Converse retractor)

-Increments of cartilaginous septum are shaved away with sharp knife under direct vision until

satifactory tip-supratip relationship is established

nb:underlying mucoperichondrium bridging upper lateral cartilages to quadrangular cartilage

is always preserved.

(Nb 2: Failure to reduce supratip in relation to ultimate tip projection is a common error

leading to a displeasing tip-supratip relationship, or "polly-beak")

Nb: except in abnormally long, drooping nose, length of upper lateral cartilages plays a small role in overall nasal length and ordinarily requires no significant shortening.

Nb: underlapping attachment of upper lateral cartilages to undersurface of nasal bones is of vital importance. If this critical supportive relationship is avulsed, repair is difficult.

SURGERY OF THE BONY VAULT

Philosophy

-Incremental removal of bone

-Preserving periosteum & soft tissue attachment over nasal bones & maxillary ascending

processes laterally Þ reduces trauma, bleeding.

Technique

-Minor Bony profile or "hump" reduction

I. Sharp tungsten-carbide down-cutting rasp - esp if minor bony hump

II. Rubin osteotome, final finishing with rasp

nb: overaggressive hump removal can be fixed by the excised bony hump being replaced

autogenous septal cartilage grafts from, alar cartilage remnants, or auricular cartilage

-Narrowing the nose: osteotomies

I Medial-oblique Osteotomies

2-3 mm osteotome

Advanced cephalically and obliquely at an angle of 15-20 degrees outward

Create a predetermined weakness for a controlled fracture

II Lateral Osteotomies

Reserved as the very last procedure

2-3 mm osteotome

No need for elevation of the periosteum - Periosteum acts as an internal splint

Osteotomy initiated at piriform aperture at or just above attachment of inf turbinate

Progress towards face of the maxilla, curving towards nasomaxillary junction to eventually encounter the medial osteotomies

Should be as low as possible to allow a large lateral wall for infraction

to prevent palpable step deformity

NB In young patients, complete fractures with total mobilization of bony pyramid is desirable.

NB In older adult less mobilization and even so-called greenstick fractures may be acceptable

III. Intermediate Osteotomies

For patients with extreme asymmetry of sidewalls

Must be carried out before lateral osteotomies

FINISHING TOUCHES

Sutures

Packing

Dressing

Ice packs and elevate head

Antibiotics

Steroids

COMPLICATIONS

Haematoma

Haemorrhage

Infection

Cosmetic deformity

Nasal airway obstruction

Ophthalmological injury

Oedema

Ecchymosis

Bibliography:

Cottle M: Nasal surgery in children: effect of early nasal injury, EENT Monthly 30:32, 1951.

Cottle M: Concepts of nasal physiology as related to nasal surgery, Arch Otolaryngol 72:11, 1960.

Cottle M, Loring R: Corrective surgery of the external nasal pyramid and the nasal septum for restoration of normal physiology, EENT Monthly 26:147, 1947.

Cummings, C. Otolaryngology.  Chapter 47

Gates G, Current Therapeutics.