Cosmetic Rhinoplasty 01-22, 24 Flashcards
A patient presents for consultation for reconstruction of a saddle deformity following nasal trauma. Structural support for dorsal augmentation and lengthening of the nose is required. Which of the following is most likely to result in secondary development of nasal asymmetry during the early postoperative period?
A) Alloplastic implant
B) Cantilevered costal bone graft
C) Cantilevered cranial bone graft
D) Carved costal cartilage graft
E) Diced cartilage graft
The correct response is Option D.
Multiple techniques have been described for dorsal augmentation in rhinoplasty. Carved costal cartilage offers structural support for both dorsal augmentation and lengthening of the nose. There is a large amount of donor material available, but carved rib cartilage is prone to warping and may result in the development of secondary deformity. Techniques, such as concentric carving and insertion of a k-wire into the graft, have been used to mitigate this, but success is very technique-dependent. Dorsal augmentation with bone grafts, such as cranial bone graft and rib, are more subject to bone resorption than warping. Diced cartilage grafts offer dorsal augmentation but do not offer structural support to lengthen the nose. These grafts are malleable in the postoperative period and potentially allow correction of minor asymmetries.
Nasal augmentation with alloplastic implants is common in Asian countries. These implants carry a risk for infection, extrusion, capsule contracture, and malposition. While rare, these complications can be severe and result in secondary deformity.
A 28-year-old woman undergoes a septorhinoplasty. Fracture of the septal L-strut will most likely result in which of the following complications?
A) Bossa formation
B) Open roof deformity
C) Pollybeak deformity
D) Rocker deformity
E) Saddle-nose deformity
The correct response is Option E.
The keystone area of the nose is the junction of the cartilaginous and bony dorsum where the paired upper lateral cartilages, septal cartilage, bony septum, and paired nasal bones meet. Much like the keystone in an archway, if this area is damaged, the archway collapses. In the case of the nose, a fracture of the septal cartilage and the bony cartilage can result in instability and collapse of the septal cartilage and middle third of the nose into the pyriform, resulting in the saddle-nose deformity. When performing a septoplasty, preservation of a 1- cm caudal × 1-cm dorsal L-strut is recommended to preserve structural integrity. Regardless of the size of the L-strut, an unrecognized intraoperative fracture can result in a saddle-nose deformity.
Bossa are knob-like projections of alar cartilage irregularities through the skin. These can form as a result of overaggressive suturing, resulting in buckling or flexing of the cartilage, cutting of the cartilages, or scar tissue contraction of the cartilages.
An open roof deformity can be seen after a dorsal hump reduction. This is the result of seeing the separation between the sidewalls of the nose and the septum through the nasal skin as the skin falls unsupported into the grooves. This deformity can be corrected either by narrowing the separation by infracture of the nasal bones or by filling the defect with spreader grafts.
A pollybeak deformity is fullness in the supratip region of the nose. This can appear as a result of ptosis of the tip in relationship to distal dorsal septum, resection of the distal dorsal septum, or scar formation in the supratip region.
A rocker deformity can occur after nasal osteotomies that go into the thicker bones above the level of the canthus and into the nasofrontal region. When the distal nasal bone is infractured medially, the superior portion of the segment moves (rocks out) laterally.
A 39-year-old man undergoes rhinoplasty at the practice. Six months after the procedure, he is displeased with the outcome and notes mild persistent tip deviation. After seeking three opinions from plastic surgeons in the community who all agree to care for him, he returns to the practice and insists that the original surgeon fix his nose because he knows that surgeon is “the best.” This patient most likely has which of the following psychological disorders?
A) Bipolar disorder
B) Body dysmorphic disorder
C) Histrionic personality disorder
D) Narcissistic personality disorder
The correct response is Option D.
Identification of various personality or psychiatric disorders prior to administering aesthetic care for patients can minimize social issues that can arise with the physician-patient relationship. Body dysmorphic disorder is hallmarked by pervasive and intrusive thoughts about a physical element (arm contour, for example) and may occupy several hours a day, causing severe distress and impairing one’s otherwise normal activities. The diagnosed individual is often the only person who can see the affliction. Histrionic personality disorder (HPD) is characterized by a pattern of excessive attention-seeking behaviors. This includes inappropriate seduction and an excessive desire for approval. People diagnosed with HPD are often lively, dramatic, vivacious, enthusiastic, and flirtatious. Narcissistic personality disorder (NPD) patients have a grandiose sense of self-importance and are preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. These patients have a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with their expectations). The ironic hallmark of the patient with NPD is that they often return for cosmetic surgery even if they are dissatisfied with the initial results. Bipolar disorder patients have extremes in mood/behavior: mania and depression. This mental illness is hallmarked by severe high and low moods and changes in sleep, energy, thinking, and behavior. These patients have periods of feeling overly happy and energized and other periods of feeling very sad, hopeless, and sluggish.
A 32-year-old man wants both cosmetic and functional improvement of his nose. He is scheduled for open rhinoplasty, submucous resection of the septum, spreader grafts, and submucous reduction of the inferior turbinates. Which of the following can be mixed with the local anesthesia to best decrease intraoperative bleeding during the rhinoplasty?
A) Aprotinin
B) Hyaluronic acid
C) Ketorolac
D) Tissue plasminogen activator
E) Tranexamic acid
The correct response is Option E.
Tranexamic acid inhibits fibrinolysis, which strengthens clots and decreases bleeding. Tranexamic acid has been shown to decrease bleeding in many plastic surgical procedures including rhinoplasty, rhytidectomy, liposuction, reduction mammaplasty, and abdominoplasty, as well as others. The method of giving tranexamic acid includes intravenous, oral, topical, and local infiltration. Studies have failed to show an increased risk for thromboembolic events. The therapeutic results last for at least 17 hours. When mixed with local anesthesia, the most common doses are 1 to 2 mg/mL. Use of tranexamic acid in plastic surgery is increasingly popular but is presently off-label.
Aprotinin also prohibits fibrinolysis; however, this drug was removed from the market in the United States because of increased mortality associated with its use. Tissue plasminogen activator activates the conversion of plasminogen to plasmin, which dissolves clots and can increase bleeding. Ketorolac is a nonsteroidal anti-inflammatory drug and inhibits platelet function. Hyaluronic acid has not been shown to decrease bleeding.
A 62-year-old married man presents for rhinoplasty with concerns for airway obstruction. He reports that he is generally unhappy with his nasal tip and that the appearance interferes with his work relationships. Which of the following patient characteristics is the strongest indicator for body dysmorphic disorder?
A) Age
B) Concerns of airway obstruction
C) Marital status
D) Report that nose affects his work relationships
E) Unhappiness with nasal tip
The correct response is Option D.
Surgeons should avoid patients who are described as “SIMON,” single, immature, male, overly expectant, and narcissistic. Male patients can have more difficulty describing their specific concerns with the aesthetic appearance of their noses, and it can be very challenging to meet expectations. They may also disguise their true motives involving rhinoplasty.
The correct answer is the patient’s report that his nose affects his work relationships. People with body dysmorphic disorder (BDD) will place a very large emphasis on the physical area that they are focused on and believe that changing the area will improve their relationships.
Concerns of airway obstruction are incorrect because male patients may disguise their true motives for seeking a rhinoplasty; this is a valid concern and can be investigated during the clinical examination.
This patient is married, which is not known to be risk factor for male rhinoplasty patients and BDD. v His age is not a known risk factor for male rhinoplasty patients and BDD.
Having a complaint about a specific part of the nose is not a known risk factor for BDD
A 45-year-old man presents 1 year after a “nose surgery” for a crooked nose and reports subjective nasal obstruction. He is diagnosed with empty nose syndrome. Overresection of which of the following structures is the most likely cause of this patient’s condition?
A) Inferior turbinates
B) Lower lateral cartilage
C) Middle turbinates
D) Septal cartilage
E) Upper lateral cartilage
The correct response is Option A.
Empty nose syndrome is characterized by a subjective sensation of nasal obstruction in the context of adequate nasal space. The differential diagnosis includes chronic rhinosinusitis, atrophic rhinitis, and autoimmune processes, and it can be diagnosed, in part, by alleviation of symptoms after the placement of a moist piece of cotton in the nose. Empty nose syndrome occurs in patients who have had turbinate surgery, and overresection of the inferior turbinates is the most common cause; some authors describe inferior turbinate resection as the “classic” cause. While middle turbinate resection can also be associated with empty nose syndrome, the middle turbinates are rarely resected during rhinoplasty. Instead, they are resected during endoscopic sinus surgery.
Resection of the upper lateral cartilage can be performed to correct middle vault deviation, and the upper lateral cartilage can be affected during dorsal hump reduction. The internal nasal valve is comprised of the nasal septum and the upper lateral cartilage; it does not contribute to empty nose syndrome. Resection of septal cartilage—both for septal cartilage graft harvest and to correct underlying septal pathology—can lead to complication, including hematoma, adhesions, structural deformity, and septal perforation, among others. It is not, however, associated with empty nose syndrome. Overresection of the lower lateral cartilage can lead to structural problems, such as inadequate tip support or alar ptosis. The lower lateral cartilage is not involved in empty nose syndrome.
A 30-year-old woman presents to the clinic with difficulty breathing. Clinical examination shows a septal deviation with contralateral inferior turbinate hypertrophy. On application of topical nasal decongestant, there is no resolution of the inferior turbinate hypertrophy. In addition to surgical correction of the deviated septum, which of the following is the most appropriate treatment for the contralateral inferior turbinate hypertrophy?
A) Complete inferior turbinectomy
B) Inferior turbinate outfracture
C) Submucosal resection
D) No additional correction is needed
The correct response is Option C.
Nasal septal deviations are commonly associated with nasal obstruction. Septal deviations can lead to compensatory hypertrophy of the contralateral inferior turbinate. It is important to differentiate between mucosal and bony hypertrophy. Mucosal hypertrophy typically responds well to topical nasal decongestant. This patient had no response with topical decongestant, signifying a primarily bony hypertrophy of the inferior turbinate.
While treating airway obstruction related to nasal septal deviations, it is important to address both the nasal septal deviation and the contralateral inferior turbinate hypertrophy, because straightening of the nasal septum will lead to narrowing of the airway if the contralateral inferior turbinate hypertrophy is not addressed.
The inferior turbinate has an important role in normal nasal physiology, and complete inferior turbinectomy is not advised since it leads to dryness, bleeding, mucosal crusting, ciliary dysfunction, chronic infection, malodorous nasal drainage, or atrophic rhinitis. In patients with nasal airway obstruction secondary to bony hypertrophy of the inferior turbinate, submucosal resection is the more appropriate treatment.
In patients with primarily mucosal hypertrophy of the inferior turbinate, inferior turbinate outfracture is usually adequate.
A 25-year-old man is concerned about the drooping tip of his nose. On physical examination, he has a dorsal hump, poor tip support, a drooping tip, excessive columella show, and a long caudal septum. Which of the following surgical maneuvers is best to correct this patient’s nasal deformity?
A) Caudal septal tongue-in-groove technique
B) Columellar strut graft
C) Lateral crura spanning sutures
D) Medial foot plate excision
E) Transdomal suture
The correct response is Option A.
To correct this patient’s deformity, control of tip support, projection, and rotation is essential. A septal tongue-in-groove technique will provide more reliable control of the tip. This is similar to a tongue-in-groove septal extension graft; however, because this patient has adequate caudal septal length, the medial crura can be elevated and rotated onto the native caudal septum. If the septum has too much length, which is rare, the caudal septum can be shortened. The tradeoff in this technique is stiffness of the tip.
Columella strut is much less reliable and unnecessary because there is adequate septal length. Medial foot plate excision (removes prominent foot plates) will not correct a drooping tip. Transdomal sutures (narrow nasal tip) and lateral crura spanning sutures (straighten convex/concave lower lateral cartilages) will not correct this deformity.
A 36-year-old woman presents for cosmetic rhinoplasty. Examination shows a retracted columella, underprojection, and underrotation of the nasal tip, along with a prominent dorsal hump. An open rhinoplasty is planned. Which of the following grafts is most likely to preserve tip rotation with time in this patient?
A) Batten
B) Columellar strut
C) Onlay
D) Septal extension
E) Spreader
The correct response is Option D.
Nasal tip refinement is one of the most critical aspects of rhinoplasty surgery. Control of the position is critical for long-term results. It is influenced by surgical approach, maneuvers, and postoperative healing. Tip support is reliant on not only the crura and ligaments holding them together, but also on the grafts utilized to support the repair. The two most common grafts that provide a great deal of support for the tip are the columellar strut graft and the septal extension graft. Although both will result in some degree of loss of projection and rotation in the immediate postoperative period, both will have similar preservation of tip projection. However, the septal extension graft is noted to have better preservation of tip rotation with time in comparison with the columellar strut graft. The remaining grafts listed do not affect the projection and rotation of the nasal tip as powerfully. Septal extension graft will more effectively lengthen a shortened caudal septum more effectively than a columella strut alone.
Which of the following treatments for inferior turbinate hypertrophy is most likely to preserve mucosal function while maximizing symptom relief?
A) Electrocautery
B) Laser cautery
C) Partial turbinectomy
D) Submucous resection
E) Turbinate outfracture
The correct response is Option D.
Submucous resection of the inferior turbinate is the most likely treatment to provide symptom relief and preserve function.
The inferior turbinate warms and moisturizes the air during breathing. Surgery is indicated for patients who have nasal obstruction refractory to medical management. Surgical treatment has focused on tissue reduction.
Submucous resection removes some of the underlying bone with preservation of overlying mucosa. It provides the largest improvement in nasal airflow, and it is the only treatment that has been shown to restore mucociliary clearance and secretory production. Complications include synechiae, crusting, and bleeding.
Partial turbinectomy involves selectively trimming of the inferior turbinate. It provides long-lasting relief but it does not preserve the function of the mucosa and has high a complication rate.
Turbinate outfracture attempts to lateralize the inferior turbinate with a blunt instrument. No objective data have been found to support long-term improvement. Early recurrence occurred in more than 50% of cases.
Electrocautery and laser cautery work by creating tissue injury and subsequent fibrosis. Long-lasting results have not been reported.
A 27-year-old woman presents to the office because of difficulty breathing. Medical history includes closed rhinoplasty with dorsal hump removal and septoplasty 3 years ago. Physical examination shows a narrowed mid vault with an inverted V deformity. Which of the following grafts is most likely to correct the patient’s condition?
A) Alar batten
B) Dorsal onlay
C) Dorsal sidewall onlay
D) Shield
E) Spreader
The correct response is Option E.
This patient has collapse of the upper lateral cartilages onto the nasal septum. This is the result of the dorsal hump reduction that released the upper lateral cartilages from the septum and then unsupported allows the upper lateral cartilages to collapse inward. The inverted V deformity is the result of the upper lateral cartilages collapsing inward away from the nasal bones, exposing their underlying shape (the inverted V shape of the piriform aperture). This also results in narrowing of the lateral dorsal aesthetic lines of the nose. This narrowing of the mid-vault of the nose is seen internally as a narrowing of the internal nasal valve.
The placement of spreader grafts between the septum and upper lateral cartilages will correct the inverted V deformity, widen the dorsal aesthetic lines, and open the internal nasal valve.
Placement of an alar batten graft, dorsal onlay graft, dorsal sidewall onlay graft, and/or shield grafts will not correct the inverted V deformity, dorsal aesthetic lines, or open the internal nasal valve. Thus their placement will not correct the aesthetic or functional issue seen in this patient.
An alar batten graft can be used to support and strengthen the alae. They often will be used to strengthen an overresected lateral crura. These grafts can also correct collapse of the external nasal valve.
A dorsal onlay graft is used to augment the dorsum or hide asymmetries.
A dorsal sidewall graft is used to camouflage depressions or asymmetries of the upper lateral cartilages. These grafts, however, will not open the internal nasal valve and will not have an effect on breathing.
A shield graft is used to improve nasal tip aesthetics. It can project the tip and create tip defining points.
Which of the following structures is associated with the anatomical boundaries of the internal nasal valve?
A) Anterior edge of the vomer
B) Anterior middle turbinate
C) Caudal border of the upper lateral cartilage
D) Cephalic border of the lower lateral cartilage
E) Foot plate of the medial crus
The correct response is option C.
The internal nasal valve is the narrowest point along the upper airway. Its cross-sectional area is determined by the anatomical boundaries. These comprise the caudal border of the upper lateral cartilage superiorly, the anterior inferior turbinate posteriorly, the caudal septum medially, the nasal floor inferiorly and the pyriform margin laterally. Numerous techniques have been described to stabilize internal nasal valve narrowing by graft/stabilization of the upper lateral cartilage to prevent collapse medially
An otherwise healthy, 40-year-old woman has a nasal deformity requiring reconstruction. A composite auricular graft is planned. Problems in which of the following anatomic areas of the nose will most likely benefit from this kind of reconstructive method?
A) Dorsum
B) Internal nasal valve
C) Sidewall
D) Tip
E) Vestibular lining
The correct response is Option E.
The anatomic area of the nose where a composite auricular graft would most likely be used is in the vestibular lining. In the event of alar retraction secondary to vestibular lining shortage, composite grafts have proven to be very effective in providing cartilaginous support in addition to lining. Alar retraction is caused by a shortage of vestibular lining. This shortage may be intrinsic, but more often it is secondary to contraction from scarring or prior surgery. If the alar retraction is caused by a shortage of vestibular lining, replacement or recruitment of nasal lining is required for adequate correction. The auricular composite graft is one method of replacing vestibular lining while also providing cartilaginous support. Following harvest of a composite graft of conchal cartilage and skin, an incision is placed within the vestibule parallel to the alar rim in the area of deficiency. Dissection is carried out to release scarring and facilitate mobility for caudal repositioning of the alar rim. The composite graft is then placed as an intervening graft within the incision and sutured in place.
The other options are usually not areas where such grafts are used.
A 45-year-old woman presents for rhinoplasty evaluation. The patient is dissatisfied with the downward movement of her nasal tip when she smiles. Which of the following muscles is responsible for this motion?
A) Alar nasalis
B) Depressor septi nasi
C) Levator labii superioris alaeque nasi
D) Procerus
E) Transverse nasalis
The correct response is Option B.
The muscles of the nose contribute to its dynamic motion. The depressor septi nasi originates from the incisive fossa of the maxilla and inserts into the nasal septum and posterior aspect of the alar nasalis. It depresses the nasal septum and causes the nasal tip to move downward on animation and narrows the columellar labial angle. Release of this muscle during rhinoplasty will reduce the nasal tip depression during animation, but can also cause upper lip ptosis.
The nasalis muscle consists of two parts: the alar nasalis and the transverse nasalis. The alar nasalis, also called the pars alaris or dilator naris, originates from the maxilla and inserts along the lateral crura. It has variable development and helps to open the external nasal valve.The transverse nasalis originates from the maxilla and traverses the nose, with a thin aponeurosis over the midline. It elongates the nose and constricts the nostrils.The levator labii superior alaeque nasi originates from the nasal bone and inserts into the nostril and upper lip, and dilates the nostrils and elevates the upper lip. It is also known as Otto’s muscle, and is the longest-named mammalian muscle.The procerus muscle depresses the glabella and assists in nostril flare.
A patient comes to the office because he is interested in rhinoplasty. He is generally satisfied with the shape of his nose when he is in repose, but he says that his nose becomes distorted when he laughs or talks. Which of the following muscles is the most likely cause of this finding?
A) Corrugator supercilii
B) Depressor septi nasi
C) Levator labii alaeque nasi
D) Orbicularis oris
E) Procerus
The correct response is Option B.
The depressor septi nasi originates on the upper lip and inserts at the base of the nose on both the septum and alae. When this muscle contracts in animation, it may pull the tip of the nose down, decrease the nasolabial angle, and elevate the upper lip. The labii alaeque nasi dilates the nostrils and lifts the upper lip. The procerus muscle lies between the eyebrows and functions to depress the medial eyebrows. Contraction creates the horizontal wrinkle at the nasion. Finally the corrugator supercilii is a pyramidal shaped muscle on the medial part of the supraorbital ridge which, when contracted, moves the eyebrows medially creating vertical wrinkles between the eyes.
A 17-year-old woman wants improvement of a large dorsal hump, hanging columella, and bulbous tip with vertically oriented lower lateral cartilages. The patient refuses the use of septal cartilage grafts. Which of the following surgical maneuvers will best avoid a dorsal inverted V deformity?
A) Internal silicone splint
B) Lateral crus mattress suture
C) Subdomalgraft
D) Tongue-in-groove tip support
E) Upper lateral spanning sutures
The correct response is Option E.
The inverted V deformity refers to the visibility of the caudal edge of the nasal bones caused by collapse of upper lateral cartilages. Dorsal reduction rhinoplasty removes the structural support provided by the connection of the dorsal septum to the paired upper lateral cartilages. The lateral cartilages have a tendency to then splay, distort, and collapse posteriorly. This can narrow the internal nasal valve and cause airway narrowing as well as aesthetic distortion of the dorsal aesthetic lines. Following takedown of a dorsal hump, upper lateral spanning sutures are used to re-establish the proper relationship of the dorsal medial edges of the upper lateral cartilages and the septum.
Use of spreader grafts will also re-establish this anatomy; however, it requires harvesting cartilage from the septum, more extensive surgery, and increased complications. In patients who require a wider angle at the internal nasal valve, the excess dorsal aspect of the upper lateral cartilages can be folded over on itself to create its own spreader graft, avoiding the need for a septal graft.
Tongue-in-groove refers to overlapping the medial crura onto the caudal septum. With an adequate caudal septum, this replaces the need for a columella graft but it will not effectively prevent inverted V deformity.
A subdomal graft is used to control the shape of the nasal tip. The cartilage removed from the dorsal hump can be used for this purpose without formal septal harvesting but the risk for a dorsal inverted V deformity does not change.
Lateral crus mattress sutures are used to straighten a concave or convex lateral crus.
Internal nasal splints are used to provide temporary postoperative support of the septum following septoplasty.
Which of the following rhinoplasty techniques is most likely to result in alar rim notching, retraction, or collapse?
A) Cephalic trim of the lower lateral cartilages
B) Failure to place a columellar strut graft
C) Failure to place spreader grafts
D) Inadequate transdomal sutures
E) Migration of a cartilage tip onlay graft
The correct response is Option A.
Of all of the options, the only one that would affect the appearance of the alar rims is the maneuver that affects the lower lateral cartilages. Weakened or overly resected lower lateral cartilages would have a tendency to result in deformities of the alar rims.
Migration of a cartilage tip onlay graft, failure to place a columellar strut graft, and inadequate transdomal sutures would affect the appearance of the nasal tip.
Failure to place spreader grafts would affect the internal nasal valve but have minimal change to the appearance of the nose.
Which of the following deformities in a patient with nasal airway obstruction is best treated with a spreader graft?
A) Bulbous tip
B) Dorsal nasal hump
C) External orifice laxity
D) Inferior turbinate hypertrophy
E) Internal nasal valve narrowing
The correct response is Option E.
All of the options can create decreased airflow on inspiration and can be improved with surgical maneuvers. The spreader graft placed between the septum and upper lateral cartilages is used to increase the internal nasal valve angle, thereby increasing inspiratory nasal air flow. Septal deviation could cause airway obstruction, but would best be treated with a septoplasty to remove septal cartilage narrowing the airway on the affected side. Significant inferior turbinate hypertrophy would be treated surgically with either fracture or resection, and external skin laxity or external nasal valve collapse would best be treated with stabilization using a cartilage graft on the lateral alar segment. Placing a spreader graft to widen the internal valve would not improve airflow in any of the other choices. Dorsal nasal hump and bulbous tip are not addressed by this maneuver.
A 35-year-old woman is evaluated because of persistent nasal airway obstruction after undergoing nasal airway surgery and rhinoplasty 6 months ago. Physical examination, including anterior rhinoscopy, demonstrates a midline septum and nasal dorsum with no evidence of nasal valve collapse. Which of the following nasal airway procedures is most commonly associated with empty nose syndrome?
A) Inferior turbinate electrocautery
B) Inferior turbinate resection
C) Microdebrider inferior turbinoplasty
D) Radiofrequency ablation inferior turbinoplasty
E) Submucosal resection septoplasty
The correct response is Option B.
The nasal airway procedure most commonly associated with empty nose syndrome is inferior turbinate resection. Empty nose syndrome is a clinical syndrome characterized by recalcitrant and paradoxical symptoms of nasal obstruction and suffocation despite a widely patent nasal airway. It is encountered as a postsurgical phenomenon associated with the loss of nasal tissues. This condition is also associated with a significant psychological burden. While the etiology of the condition remains unclear, its association with nasal surgeries, particularly with surgical manipulation of the inferior turbinate, is well-documented. Appreciation of this potential clinical syndrome may help nasal surgeons avoid secondary interventions that are potentially low-yield.
While empty nose syndrome has been reported after a great variety of nasal surgeries, it is most commonly associated with over-aggressive resection of the inferior turbinate. Patients with empty nose syndrome have a significantly smaller inferior turbinate volume compared to control groups on CT analysis. While any inferior turbinate surgery could potentially result in empty nose syndrome, it is much less commonly associated with submucosal reductions of the glandular tissue of the inferior turbinate. Microdebrider inferior turbinoplasty, radiofrequency inferior turbinoplasty, and electrocautery inferior turbinoplasty all represent different energy sources to accomplish the submucosal reductions from inferior turbinate hypertrophy.
All inferior turbinoplasties, compared with inferior turbinate resections, are less commonly associated with empty nose syndrome and maintain the bony structure and mucosal coverage of the inferior turbinate. A recent meta-analysis suggests there are no differences between the two most common techniques, microdebrider and radiofrequency, in overall efficacy for nasal obstruction. Similarly, the risk for complications, including persistent nasal obstruction (including the possibility of empty nose syndrome), between these two techniques is similar. Septoplasty is the most common nasal surgery for nasal obstruction, and the submucosal technique is the most frequently employed. This technique has the advantage of maintaining the nasal mucosa while repairing the structural causes of nasal airway obstruction.
Submucosal resection septoplasty is incorrect because there are limited reports of empty nose syndrome associated with septoplasty.
A 26-year-old woman is evaluated because she has difficulty breathing out of her right nostril. Physical examination shows the nasal septum is deviated to the right. The nasal dorsum is straight, and the nasal tip is slightly underprojected. A septoplasty is planned. Which of the following incisions is most appropriate for accessing the septum?
A) Intercartilaginous
B) Killian
C) Marginal
D) Rim
E) Weir
The correct response is Option B.
A Killian incision is made 1-2 cm posterior to the caudal edge of the septum and provides access to the septum for a septoplasty. It is the most appropriate of the choices listed. While the Killian incision does not provide access to the caudal septal angle, it preserves tip support. The transfixion incision, which obtains access to the septum by incising both sides of the membranous septum at its junction with the caudal septum, is sometimes used. Both provide access to the septum, but the transfixion incision disrupts the septal ligaments, which can deproject the nasal tip inversely. When nasal tip deprojection is desired, the transfixion incision is used, and when the nasal tip is slightly under projected, a Killian incision can be considered.
The Weir incision is made at the alar base. The marginal incision is made at the caudal aspect of the lower lateral cartilage, and the rim incision is made at the rim. Though often grouped together, these incisions are distinct. The intercartilaginous incision is made between the upper lateral and lower lateral cartilages. These incisions are not used for septoplasty.
The septum can also be accessed through a transcolumellar approach, which is an open approach.
A 35-year-old woman comes to the office for correction of an irregularity of the nasal dorsum following rhinoplasty performed 1 year ago. The patient wants nonsurgical treatment. Hyaluronic acid filler (0.6 mL) is injected into the upper third of the nasal dorsum. Immediately after injection, the patient reports partial loss of vision and pain in the right eye. Which of the following is the most appropriate next step?
A) Application of apraclonidine eye drops
B) Intravenous infusion of tissue plasminogen activator
C) Nasal subcutaneous injection of hyaluronidase
D) Percutaneous lateral canthotomy
E) Retrobulbar injection of hyaluronidase
The correct response is Option E.
This patient has symptoms of an intravascular injection of hyaluronic acid (HA) causing occlusion of the central retinal artery. This complication is extremely rare; however, when it occurs, treatment must be immediately instituted because the retinal circulation needs to be restored quickly (within 60 to 90 minutes) for possible reversal of symptoms.
The first line of treatment is to bathe the retinal circulation with hyaluronidase. This is achieved with a retrobulbar injection. Using a 25-gauge needle or cannula, enter the orbit along the orbital floor between the inferior and lateral rectus muscles. Advance the needle along the orbital for at least 1 inch beyond the orbital rim and inject 2 to 4 mL of undiluted hyaluronidase. Hyaluronidase adjacent to an occluded vessel can dissolve an HA embolus.
The likely mechanism of vascular occlusion is an intra-arterial injection of filler under pressure. In this case, the filler would have entered the dorsal nasal artery and traveled retrograde to the ophthalmic artery. Once the injection pressure is released, the filler would then flow antegrade into the central retinal artery which is the terminal branch of the ophthalmic artery.
Tissue plasminogen activator would be indicated for hematologic thrombosis or blood clot embolism, not HA embolus.
Subcutaneous injection of hyaluronidase is indicated for treatment for filler-related vascular compromise secondary to extravascular compression. The goal is to dissipate the extravascular compression of the artery. However, in patients with symptoms of vision loss, the likely diagnosis is a HA embolus and therefore the first injection should be retrobulbar.
Lateral canthotomy is indicated for decompression or a retrobulbar hemorrhage. Reassurance is not a reasonable treatment option as this is an emergency. Apraclonidine is a sympathomimetic eye drop use to stimulate Müller muscle and improve botulinum toxin type A–related ptosis.
A 25-year-old man who underwent septorhinoplasty 6 weeks ago is evaluated because of clear nasal discharge. He notes that the drainage worsens when he bends forward or strains, and the discharge tastes salty. Physical examination shows a small amount of watery drainage from the right nostril. Examination with a nasal speculum shows no other abnormalities. Which of the following is the most appropriate next step in management?
A) MRI of the skull base
B) Testing of fluid for beta-2 transferrin
C) Testing of fluid for glucose
D) Trial of a corticosteroid nasal spray
E) Trial of an oral antihistamine
The correct response is Option B.
The patient in question presents with a history that is suggestive of cerebrospinal fluid (CSF) leak following septoplasty. Patients with such a leak typically have unilateral clear nasal discharge that tastes salty or metallic. Straining, Valsalva maneuver, or leaning forward typically make the drainage worse.
Commonly, rocking or twisting forces applied during the septoplasty cause a traumatic injury to the cribriform plate, with a resultant CSF leak. The injury is more common (2:1) on the right side and is more common in men.
Beta-2 transferrin testing on the CSF fluid is very specific for the injury. This protein is only found in CSF, but the test is not available in all centers. Testing the fluid for glucose is not specific and has a high false-positive rate. MRI of the skull base is not particularly helpful for CSF leaks. High-resolution CT is preferred.
Steroid nasal spray and antihistamines are not used in the management of CSF rhinorrhea.
A 32-year-old woman is evaluated for rhinoplasty. In the course of evaluation, the Cottle maneuver is performed. This test is most likely performed to evaluate which of the following?
A) Collapse of the external nostrils
B) Hypertrophy of the inferior turbinate
C) Patency of the internal nasal valves
D) Presence of septal perforation
E) Septal mucosal thickening
The correct response is Option C.
Nasal airway obstruction is a common symptom among patients presenting for rhinoplasty. Evaluation of the nasal airway should be performed in all patients presenting for rhinoplasty. The key structures that affect nasal airflow include the external and internal nasal valves, the inferior turbinates, and the nasal septum. The patient should be examined for collapse of the external nasal valves on deep inspiration, and a Cottle maneuver should be performed to evaluate patency of the internal nasal valves. Internal nasal examination is aided with the use of a nasal speculum. Oxymetazoline nasal spray facilitates mucosal constriction if mucosal edema is present. Narrowing or collapse of the internal valves with inspiration should be noted, along with inferior turbinate hypertrophy, which typically occurs on the side opposite septal deviation.
When a cephalic trim is performed during primary rhinoplasty, which of the following is the minimum width of caudal lower lateral cartilage that should be left behind?
A) 4 mm
B) 6 mm
C) 8 mm
D) 10 mm
E) 12 mm
The correct response is Option B.
The nasal tip represents a complex nasal tripod. The paired lower lateral cartilages work synergistically to provide the main structural support for the nasal tip. Tip refinement is of course common in rhinoplasty, and a cephalic trim of excess lower lateral cartilage is a classic maneuver utilized in primary rhinoplasty. The cephalic trim acts to decrease vertical height of the lateral crura and to debulk to tip. It is crucial that enough cartilage be left behind when removing excess lower lateral cartilage from the cephalic portion. Classically, 6 mm (5 to 7 mm) of rim strip is the accepted standard of how much should be left behind at minimum to prevent stability compromise of the lower lateral cartilages. Resection in excess of this can weaken the lateral crus and cause retraction, notching, and/or external valve dysfunction.
A 30-year-old woman wants improvement of the bulbous tip of her nose. Open rhinoplasty and thinning of the tip is planned. Intraoperative examination shows the cause of the bulbous tip is widely convex lower lateral cartilages that are thick and relatively inflexible. The domal width is greater than 6 mm. The angle of divergence is normal. Which of the following surgical maneuvers is most likely to correct the deformity?
A) Alar rim grafting
B) Cephalic trimming of the lower lateral cartilage
C) Crural spanning sutures
D) Lateral crural strut grafting
E) Subdomal spreader grafting
The correct response is Option D.
A bulbous/boxy tip can be caused by a convex lower lateral cartilage with a wide domal width (less than 4 mm), widened angle of divergence (less than 30 degrees), or a combination of both. This patient’s deformity is a widely convex lower lateral cartilage. The best choice is a lateral crural strut graft. This graft is usually harvested from the septum and sutured to the undersurface of the lower lateral cartilage. These grafts are strong and can reshape a thick inflexible lower lateral cartilage. Crural spanning sutures can straighten the convexity of these cartilages if the cartilages are flexible; however, in this patient it would unlikely be successful.
Transgenu sutures are often needed to further refine the domal width; however, in very boxy tips, a lateral crural strut graft would also be needed for a better result. Cephalic trim of the lower lateral cartilage is often performed to narrow the cartilage. This maneuver would not correct the deformity. When performing the cephalic trim, it is important to leave at least 6 mm of cartilage for support. An alar rim graft is a strip of cartilage places is a subcutaneous pocket along the alar rim. This graft is placed caudal to the lower lateral cartilage. It can strengthen a buckled rim but would not straighten a stiff convex lower lateral. Subdomal spreader grafts are used to correct a pinched tip deformity.
A 23-year-old woman of Asian ancestry comes to the office to discuss augmentation rhinoplasty to address dorsal projection. She refuses harvest of graft material from a secondary donor site. Which of the following materials would most likely provide the desired augmentation, the least surgical risk, and the greatest longevity of result?
A) Ear cartilage
B) Homologous irradiated rib cartilage
C) Porous polyethylene implant
D) Septal cartilage
E) Stacked acellular dermal matrix
The correct response is Option D.
There are many options for materials to use for augmentation rhinoplasty. Most options fall into one of several categories including autologous soft tissue, cartilage, and bone; processed allografts such as acellular dermal matrix; homologous grafts, most often irradiated rib; and alloplastic materials including silicone, ePTFE (expanded polytetrafluoroethylene sheeting), and porous polyethylene. There are advantages and disadvantages of each. In this case, the patient refuses a donor site outside of the nasal surgery, which eliminates the options of ear or rib cartilage and the option of cultured autologous auricular chondrocytes, as this too requires harvest of ear cartilage prior to the rhinoplasty. Homologous irradiated rib cartilage is a good alternative to autologous cartilage grafts and requires no donor site but has a somewhat higher risk profile than autologous septal cartilage. Silicone implants, and alloplastic implants in general, are popular in Asian augmentation rhinoplasties and have the advantage of availability, affordability, and no donor site, but they carry a higher risk for postoperative complications, including extrusion, skin changes, and infection, all of which create significant issues when they require secondary rhinoplasty procedures. Acellular dermal matrix has the disadvantage of a resorption rate of 20 to 30 percent, too much to perform precise corrections. An ear cartilage graft would be from a secondary site.
During secondary open rhinoplasty through an existing transcolumellar incision, division of which of the following arteries is most likely to result in vascular ischemia of the nasal tip?
A) Anterior ethmoid
B) Columellar
C) Dorsal nasal
D) External nasal
E) Lateral nasal
The correct response is Option E.
A detailed knowledge of the nasal tip blood supply is critical for safe conduct when using a transcolumellar incision during primary or secondary rhinoplasty. There are several sources of arterial blood supply to the nasal tip. Some of these can be sacrificed without compromising the viability of the nasal tip skin. Rohrich et al. determined that the nasal tip has a dual blood supply derived from the ophthalmic and facial arteries. While contributions from the ophthalmic circulation’s anterior ethmoid, dorsal nasal, and external nasal arteries are present, the dominant supply is derived from branches of the facial artery. Its branches, the columellar artery (present in 68.2% of cadavers in one study) and the lateral nasal artery (present in 100% of cadavers), are more likely to provide the nasal tip with inflow even if the ophthalmic arterial branches are sacrificed during the dissection. Regardless of the presence of a prior transcolumellar incision, the nasal tip blood supply is secure if the lateral nasal arteries are preserved. Guidelines for assuring that the lateral nasal arteries remain uninjured include “hugging” the cartilage of the lateral crura in a subperichondrial plane, limiting dissection superiorly to the level of the alar groove, limiting alar base excision to a level below the alar grooves, and limited defatting of the subdermal plane of the tip.
A 35-year-old man comes to the office for a consultation because he is dissatisfied with the result of a rhinoplasty performed 2 years ago. The patient reports that his nasal openings collapse on deep inspiration and his nasal tip is deformed. Physical examination shows collapse of the external nasal valve on deep inspiration and bilateral asymmetric alar rim collapse with alar retraction of 1 to 2 mm. Revision rhinoplasty is planned. Which of the following grafts is most appropriate to correct these conditions?
A) Columella strut
B) Composite alar rim
C) Lateral crural strut
D) Spreader
E) Subdomal
The correct response is Option C.
The lateral crural strut graft is a strip of septal cartilage that (if available for harvest) is sutured to the underside of the lower lateral cartilage and provides increased support and position control. It is a very powerful graft that can reposition lower lateral cartilages, correct alar retraction, and correct external valve collapse.
The columella strut graft is for increased tip projection and support.
The composite alar rim graft includes both skin and cartilage. This graft is used for severe alar retraction and soft tissue loss of the alar rim.
Spreader grafts are used to increase airflow through the internal nasal valve as well as straighten a deviated dorsal septum and improve dorsal aesthetic lines.
The subdomal graft is placed under the domes of the lower cartilages and can correct asymmetry of the nasal tip and improve a pinched tip.
A patient is evaluated because of nasal airway obstruction that is worse on the right side. Physical examination shows the inferior nasal turbinate has significant anterior extension and mucosal thickening with bony hypertrophy. There is a posttraumatic septal deviation and a 10-degree internal nasal valve angle. In consideration of surgery to improve the nasal airflow, which of the following factors is most important in determining the need for a submucous resection of the turbinate?
A) Anterior extension of the turbinate
B) Bony hypertrophy
C) Decreased internal nasal valve angle
D) Deviated septum
E) Mucosal thickening
The correct response is Option B.
All of the answers listed can play a part in this patient’s nasal obstruction and poor airflow in the right nostril. Of the answers listed, the bony hypertrophy of the inferior turbinate is the finding which most suggests the need for a submucous resection. The anterior extension of the inferior turbinate certainly can play a role in decreased air flow, but this by itself does not suggest the need for submucous resection. Simple mucosal thickening of the inferior turbinate without bony hypertrophy can be addressed with outfracture. Septal deviation can be addressed with septoplasty. Decreased internal nasal valve angle can be addressed with, for instance, a spreader graft.
At the keystone area of the nose, which of the following most accurately describes the anatomic position of the upper lateral cartilage in relation to the nasal bones?
A) Anterior to the nasal bones
B) Caudal to the nasal bones with a 1 to 2 mm fibrous gap
C) Edge to edge with the nasal bones with no overlap
D) Posterior to the nasal bones
The correct response is Option D.
The keystone area of the nose is where the nasal bones overlap the upper lateral cartilages. This is usually the widest part of the nasal dorsum.
At the dorsal keystone area, the nasal bones overlap the upper lateral cartilages for a distance of 4 to 14 mm.
When reducing a dorsal hump, rasping of the bone at the keystone area uncovers the underlying cartilages, which often dictate the width of this area. Once uncovered, these structures may need to be reduced for a more aesthetic dorsal line.
In large cadaver studies, all noses demonstrate that the upper lateral cartilages are posterior to the nasal bones at the keystone area, and as such all other answer choices are incorrect.
A 30-year-old man comes to the office because of a frontal headache and persistent watery drainage from the right nostril 2 weeks after undergoing septorhinoplasty. Which of the following is the most appropriate next step in management?
A) Place nasal packing for 48 hours
B) Start oral antihistamines
C) Start vasoconstrictor nasal spray
D) Test nasal discharge for beta-2 transferrin
E) Reassure the patient that these symptoms are normal
The correct response is Option D.
Postoperative cerebrospinal fluid (CSF) leak is a rare but known complication following septoplasty. It is related to an error in surgical technique, with overly forceful manipulation of the perpendicular plate region resulting in a cribriform plate defect. The cardinal symptoms are frontal headache and a clear, watery persistent rhinorrhea. If nasal packing is present, the patient may report a metallic or salty-tasting post-nasal drip. Prompt diagnosis is required to avoid complications, particularly meningitis and pneumocephalus. CSF rhinorrhea is more common on the right side, reflecting a predominance of left-sided surgical approaches. It may present in an early manner, as in this case, or have a delayed presentation; some documented reports have a 20-year delay between septoplasty and diagnosis of CSF leak.
While imaging is beneficial, initial diagnosis of CSF leak can be made with the beta-2 transferrin or Beta-trace protein testing, which are both specific and sensitive for CSF. Both are more accurate than the traditional “halo” sign or measuring the glucose level of the fluid.
The other options listed are incorrect, as they do not diagnose or effectively treat the underlying problem.
Which of the following structures is an anatomical component of the internal nasal valve?
A) Anterior portion of the middle turbinate
B) Caudal edge of the upper lateral cartilage
C) Cribriform plate of the ethmoid
D) Ostium of the maxillary sinus
E) Superior border of the nasal bone
The correct response is Option B.
The internal nasal valve is an anatomical structure composed of several parts. Its cross-sectional dimension determines the quantity of airflow that passes through the nose while breathing both at rest and during exercise. Because it is the narrowest part of the entire airway, compromise of any of its elements correlates with symptoms of nasal obstruction. The internal nasal valve is bounded by the caudal border of the upper lateral cartilage superiorly, the nasal septum medially, the floor of the nasal vestibule inferiorly, the anterior part of the inferior turbinate posteriorly, and the bony edge of the pyriform aperture laterally. Internal nasal valve narrowing may be due to one or more of several factors, including septal deviation, turbinate hypertrophy, collapse of the upper lateral cartilage due to surgical disruption of the ligaments which support it to adjacent structures, and loss of cartilage strength due to aging. A variety of techniques have been described for restoration of the internal valve function. Most of these involve stiffening the upper lateral cartilage with cartilage graft struts, submucous resection of the nasal septum, reduction of hypertrophic turbinates, or combinations of these procedures.
A healthy 26-year-old woman undergoes rhinoplasty using a spreader graft. Which of the following is the most likely cause of decreased airway resistance after placement of the spreader graft?
A) Decreased angle at the external nasal valve
B) Decreased area of airway
C) Decreased radius at the internal nasal valve
D) Increased angle at the external nasal valve
E) Increased radius at the internal nasal valve
The correct response is Option E.
A spreader graft is placed between the septum and the upper lateral cartilages. Poiseuille law states that resistance = (viscosity × length)/radius4. About half of nasal airway resistance occurs at the internal nasal valve. The internal nasal valve, formed at the junction of the septum (medially), the nasal floor (inferiorly), the inferior turbinate (laterally), and the caudal border of the upper lateral cartilages (superiorly), accounts for a significant amount of airway resistance. Maneuvers that increase the radius at the internal nasal valve will decrease resistance exponentially.
A 35-year-old woman is dissatisfied with the appearance of her nose. Physical examination shows parenthesis tip deformity with vertically oriented lower lateral cartilages. Which of the following grafts is most appropriate for correction of this deformity?
A) Caudal septal extension
B) Crural turnover
C) Lateral crural strut
D) Spreader
E) Spring
The correct response is Option C.
This patient presents with a parenthesis deformity with vertically oriented lower lateral cartilages. To correct this deformity, the lower lateral cartilages must be rotated inferiorly. A lateral crural strut graft is a strip of cartilage 3 to 4 mm in width sutured to the deep surface of the lateral crura and then either buried or sutured to the soft tissue of the pyriform aperture. In this way, the native lower lateral cartilage can be rotated inferiorly and held in place.
A caudal septal extension graft is sutured to the caudal septum and is used to control nasal tip projection as well as lengthen an overly shortened nose.
A crural turnover graft is created by folding the cephalic portion of the upper lateral cartilage inferiorly onto itself. It thereby strengthens itself and is used to support weakened or collapsed lower lateral cartilages.
Spreader grafts are placed at the dorsal edge of the septum to correct internal nasal valve collapse and support the upper lateral cartilages.
A spring graft widens the middle vault by spanning between both upper lateral cartilages.
A 22-year-old woman is evaluated for revision rhinoplasty. A closed approach is planned. The alar margin is in an appropriate position. On lateral view, excessive columellar show is noted. Which of the following incisions is most appropriate for management of this deformity?
A) Alar rim
B) Intercartilaginous
C) Intracartilaginous
D) Killian
E) Transfixion
The correct response is Option E.
On anterior/posterior view, the alar margin and columella have been described as ideally having the appearance of a gentle gull wing in flight. The columella represents the body of the gull and in this patient it is noted to be elongated with the wings (alar margin) appearing to be normal. On lateral view, the nostril should have an oval shape. A line drawn along the long axis should bisect it into equal halves with the alar rim being 1 to 2 mm above this line and the columella 1 to 2 mm below.
The patient described exhibits findings consistent with a hanging columella. The etiology of this problem is due to either a long caudal septum, long medial crura, or combination of the two. The transfixion incision is in the membranous septum at the border of the caudal septum. It is the only incision listed above that allows access to the caudal septum for excision and can also resect any redundant membranous septum that may develop as a result of the setback.
An intracartilaginous incision is made within the substance of the lateral crus of the lower lateral cartilage. It can be used in a closed approach to combine the incision for the access to the nose with the removal of the cartilage superior to the incision to accomplish a cephalic trim of the lower lateral cartilage.
A Killian incision is used for access to the septum. It is placed 1 to 2 cm posterior to the caudal border of the septal cartilage.
An alar rim incision is made in the vestibular skin just inside the border of the nostril. This incision can be used as an approach to create a pocket for a nonanatomical rim graft.
The intercartilaginous incision is made between the upper and lower lateral cartilages and would not improve columellar show.
A 23-year-old woman comes to the office for consultation regarding rhinoplasty because she is dissatisfied with her smile. Physical examination shows a drooping nasal tip, shortened upper lip, and transverse upper lip crease when the patient smiles. Which of the following muscles is the most likely cause of these findings?
A) Depressor anguli oris
B) Depressor septi nasi
C) Levator anguli oris
D) Levator labii superioris
E) Nasalis
The correct response is Option B.
The depressor septi nasi muscle is a small, paired muscle located on both sides of the nasal septum, originating from the medial crural footplates. Its action pulls the nasal tip downward and shortens the upper lip. The overactive muscle can cause the “smiling deformity” in the patient described. It is important to evaluate the smile of the rhinoplasty patient to determine whether the depressor septi nasi muscle needs to be addressed during the procedure in order to optimize results. The depressor septi nasi muscle can be released from the medial crura through the trans-nasal approach. If the patient has tethering of the frenulum, a depressor septi nasi muscle dissection and transposition can be performed through the trans-oral approach.
The depressor anguli oris originates from the mandible and inserts into the angle of the mouth. It depresses the corner of the mouth and is associated with frowning, and does not affect the nasal tip or upper lip.
The nasalis consists of two parts: transverse and alar. The transverse part arises from the maxilla, above and lateral to the incisive fossa; its fibers proceed upward and medial, expanding into a thin aponeurosis which is continuous on the bridge of the nose with that of the muscle of the opposite side, and with the aponeurosis of the procerus. The alar part is attached by one end to the greater alar cartilage, and by the other to the integument at the point of the nose. The transverse part compresses the nostrils, drawing them toward the septum. The alar part dilates, or flares, the nostrils. While the nasalis is involved in nasal movement, it does not cause the smile deformity described.
The levator anguli oris arises from the canine fossa, located under the infraorbital foramen. The muscle’s fibers insert at the mouth’s angle, and it intermingles with the zygomaticus, triangularis, and orbicularis oris muscles. Although the muscle is involved in and helps form the smile, it elevates the angle of the mouth at the corner and is not involved in nasal tip drooping and shortened upper lip.
The levator labii superioris is a broad, flat, quadrangle muscle, and may be considered as three parts extending between the lateral side of the nose and the zygoma in the infraorbital area: angular (medial), infraorbital (intermediate), and zygomatic (lateral) head. The medial part of the angular head inserts into the greater part of the lower lateral cartilages and nasal skin, and helps dilate the nostrils. The lateral part of the angular head, infraorbital, and zygomatic head all insert by merging with fibers of the orbicularis oris, and serve to elevate and evert the upper lip, the primary function of the muscle. Although it may contribute to shortening the upper lip upon activation, it does not cause nasal tip droop.
A 27-year-old woman comes to the office for evaluation of her nasal tip. She asks for rhinoplasty for improvement of her aesthetic appearance. Physical examination shows asymmetric projection of the nasal tip with a pinched nasal deformity. Which of the following cartilage grafts would best correct this deformity?
A) Columellar strut
B) Lateral crural strut
C) Septal extension
D) Spreader
E) Subdomal
The correct response is Option E.
Correction of aesthetic and functional deformities of the nasal tip requires an understanding of the underlying anatomy and the use of cartilage grafting. A pinched nasal tip deformity results from decreased interdomal distance or narrow domal arches of the lower lateral cartilages.
Subdomal grafts can be used to correct a pinched nasal tip deformity as well as asymmetry of the domes. The subdomal graft is bar shaped, spanning beneath both domes, controlling the horizontal and vertical orientation of the domes.
The columellar strut graft corrects an underprojecting tip by increasing tip projection. The lateral crural graft is utilized to correct alar contour deformities secondary to deformed lateral crus of the lower lateral cartilages. Septal extension grafts control projection, shape, and rotation of the nasal tip. The spreader graft will expand the internal nasal valve and middle one-third of the nose but not correct a pinched tip.
The intercartilaginous incision in rhinoplasty follows the caudal border of which of the following?
A) Alar lateral crus
B) Caudal septum
C) Lower lateral cartilage
D) Middle crus
E) Upper lateral cartilage
The correct response is Option E.
The intercartilaginous incision follows the caudal border of the upper lateral cartilage and is located between it and the cephalad border of the alar lateral crus. This incision may connect, and frequently does, with a transfixion incision at the caudal border of the septum at the septal angle.
A 30-year-old man comes to the office because of symptoms of nasal airway obstruction. Physical examination shows a septal C-shaped deformity without dorsal deviation; Cottle maneuver is negative, and external nasal valves are competent. Which of the following is the most appropriate surgical management?
A) Alar batten grafting
B) Columellar strut grafting
C) Septoplasty
D) Spreader grafting
E) Submucous septal resection
The correct response is Option E.
In the patient described, the most appropriate surgical management is submucous septal resection. The important structures that affect nasal airflow and lead to obstruction are the internal and external nasal valves, the inferior turbinates, and the nasal septum. According to the classifications of the deviated nose, the patient described exhibits caudal septal deviation, with a concave (C-shaped) deformity of the septum. This is the most likely cause of this patient’s obstruction symptoms. In the absence of internal (negative Cottle maneuver) and external nasal valve collapse, resection of the deviated septum is the maneuver most likely to improve the patient’s nasal airflow and alleviate obstruction symptoms. It is of the utmost importance to preserve 9 to 10 mm L-strut of septal cartilage to maintain structural integrity.
Alar batten grafts are placed in a pocket extending from the piriform aperture to a paramedian position in the alar sidewall. They prevent lateral nasal wall collapse and alar retraction during inspiration. They are also effective in providing strength and competency to the external nasal valves. The patient has competent external nasal valves, and thus, alar batten grafts alone will not address his nasal airway obstruction, which is caused by his deviated septum. Alar batten grafts are also used as an adjunct graft to correct a caudal septum deviation after septal resection.
Columellar strut graft is placed between the medial crura for nasal tip shaping and support. Open rhinoplasty approach may cause mild loss of tip projection caused by disruption of ligamentous support and increased skin undermining, and a columellar strut will help maintain tip support. It can be used to increase nasal tip projection effectively. It does not play a role in alleviating airway obstruction caused by septal deviation.
Septoplasty is the scoring of the quadrangle cartilage to influence its shape, in an attempt to straighten it. The cartilage will bend away from the scored surface. It is an important adjunct to septal resection to shapen and straighten a deviated septum. It is likely not powerful or predictable enough to correct a septal C-shaped deformity on its own and alleviate nasal obstruction.
Spreader grafts are usually paired, longitudinal grafts placed between the dorsal septum and the upper lateral cartilages in a submucoperichondrial pocket. They are used to restore or maintain the internal nasal valve, straighten a deviated dorsal septum, improve the dorsal aesthetic lines, and reconstruct an open roof deformity. They are often placed in addition to septal resection. In the patient described, without internal nasal valve collapse and a deviated septum, spreader grafts alone will not likely improve nasal airway obstruction.
A 25-year-old woman undergoes rhinoplasty to correct a bulbous tip. After a cephalic trim leaving 6 mm of the lower lateral cartilage, transdomal sutures, and infracture, the tip continues to look bulbous. Which of the following techniques is most likely to improve this persistent deformity?
A) Additional cephalic trimming
B) Columellar strut grafting
C) Lateral crural mattress suture
D) Shield grafting
E) Spreader grafting
The correct response is Option C.
The most likely cause for a persistent bulbous tip after traditional maneuvers is convexity of the lower lateral cartilages. Lateral crural mattress sutures are effective in improving this convexity. These sutures are placed spanning the convexity and then tightened to straighten the curvature. Another option would be an alar batten graft, which is a graft placed on the medial surface of the lower lateral cartilage. Additional cephalic trim could lead to weakening of the nasal tip support and would not correct the problem. Columellar strut grafting, shield grafting, and spreader grafting will not effectively improve a naturally convex lower lateral cartilage.
Which of the following is the most appropriate method for demonstrating objective, dynamic nasal cavity patency and nasal function?
A) Anterior rhinoscopy
B) Cottle maneuver
C) Nasal endoscopy
D) Rhinomanometry
E) Sound wave analysis
The correct response is Option D.
Subjectively, the nasal valve can be assessed using the Cottle test. Anterior rhinoscopy is an objective way to evaluate the nasal cavity; however, the examiner’s assessment of how much of the nasal cavity is obstructed or patent is subjective. Nasal endoscopy, CT scan, and MRI are described as tests capable to assess the nasal cavities, helping in the diagnosis of anatomical variations associated with nasal disorders. Objectively speaking, rhinomanometry is a dynamic way to assess nasal cavity patency and nasal function; it aims at establishing nasal resistance, which is the difficulty of passing air through the nose, through the measurement of transnasal pressure and airflow. Analysis of sound waves is a static way to assess nasal patency and geometry quantifying the areas of nostril cross section all the way to the nasopharynx and nasal cavity volume between the two cross-sectional areas chosen.
A 32-year-old Korean man comes to the office for evaluation of a wide nose with decreased projection. He desires rhinoplasty for an improved aesthetic appearance. Compared with Caucasian nasal anatomy, which of the following is most likely in this patient?
A) Height of the lower lateral cartilage is shorter
B) Height of the upper lateral cartilage is longer
C) Length of the septal cartilage is longer
D) Length of the upper lateral cartilage is shorter
E) Overlapping length of the upper lateral cartilage and the nasal bone is shorter
The correct response is Option A.
The cartilaginous structures of Asian noses are substantially different from those of Caucasian noses in terms of the shape, size, thickness, and relationship to other structures. The lengths of the upper and lower lateral cartilage of Asian noses are similar to those of Caucasian noses. However, the heights of the upper and lower lateral cartilage of Asian noses are shorter than those of Caucasian noses. Therefore, rhinoplasty with cephalic resection of the lower lateral cartilage in Asian noses should be approached with caution to prevent overresection. The overlapping length of upper lateral cartilage and nasal bone is similar in both Asians and Caucasians.
A 35-year-old man comes to the office 4 weeks after undergoing open rhinoplasty and submucous resection of a deviated septum. He reports nasal crusting, bleeding, and a whistling sound from his nose. Which of the following is the most likely diagnosis?
A) Exposed conchal bone
B) Internal nasal valve collapse
C) “L” strut fracture
D) Septal perforation
E) Submucous hematoma
The correct response is Option D.
Symptoms of septal perforations include crusting along the septal defect, bleeding, and whistling. The whistling sound is due to the altered airflow pattern. Perforations can be caused by trauma, cocaine snorting, and infectious or inflammatory causes. In this patient, surgical trauma is the most likely cause. Treatments for symptomatic septal perforations include flaps and grafts. Asymptomatic perforations do not require treatment.
The symptoms of internal nasal valve collapse, and submucous hematoma would be restricted airflow. “L” strut fracture or collapse would occur with an external deformity and not the symptoms described. Exposed conchal bone is caused by overresection of inferior turbinate mucosa. When performing a submucosal resection of the inferior turbinate, this would not occur with a submucous resection of the septum.
A 35-year-old woman is scheduled to undergo functional septorhinoplasty for nasal airway obstruction. In this patient, perioperative administration of corticosteroids is most likely to have which of the following effects on edema and ecchymosis?
Edema Ecchymosis
A)Decreased Decreased
B)Decreased No Change
C)Increased Increased
D)No Change Decreased
E)No Change No Change
The correct response is Option A.
Minimizing complications after rhinoplasty is a priority for every surgeon performing the procedure. Perioperative steroid administration has been shown to decrease postoperative edema and ecchymosis in a number of prospective randomized trials. In an effort to further elucidate the significance of the data and develop an evidence-based algorithm for steroid administration, a meta-analysis of the existing literature was performed. All articles were reviewed for relevant data, which were extracted, pooled, and compared. Seven prospective randomized trials investigating perioperative steroid use in rhinoplasty have been conducted and reported. Four of these studies had the same method of patient edema and ecchymosis assessment, and their data were compared. Based on results from the four relevant studies, perioperative steroid use significantly reduces postoperative edema and ecchymosis of the upper and lower eyelids at 1 day and 7 days postoperatively (P < .0001). Preoperative steroid administration decreases postoperative upper and lower eyelid edema at 1 day preoperatively, when compared with postoperative administration (P < .05). Extended dosing is superior to one-time dosing (P < .05). Perioperative steroid use decreases postoperative edema and ecchymosis associated with rhinoplasty. Preoperative administration is superior to postoperative, and extended dosing is superior to singular. Based on these results, evidence-based guidelines for perioperative steroid administration can be given.
A 29-year-old woman comes to the office 1 year postoperatively after rhinoplasty with slight irregularities and asymmetry of the nasal bridge and tip. Physical examination shows mild depression of the nasal dorsum and asymmetric alar domes. Injection of a calcium hydroxyapatite gel is planned. Which of the following combinations of injection depth and anatomical location is most appropriate in this patient to minimize complications?
A) Subcutaneous area into the nasal alae
B) Subcutaneous area into the nasal alar domes
C) Subperiosteal area into the nasal sidewall
D) Supraperichondrial area into the nasal dorsum
E) Supraperichondrial area into the nasal tip
The correct response is Option D.
Soft-tissue fillers are minimally invasive and offer an attractive alternative to revision rhinoplasty. A variety of fillers are available, including hyaluronic acid derivatives, calcium hydroxyapatite gel, and silicone. Because of the risk of adverse reactions, silicone injectables should be avoided. Hyaluronic acid-derived and calcium hydroxyapatite fillers are better tolerated but still may occasionally cause infection, necrosis, or thinning of the soft-tissue envelope. To minimize the risk of these complications, fillers should be placed in the sub-superficial musculoaponeurotic system plane just above the plane of the periosteum. This will lessen the chance of visibility and palpability. Also, use should be restricted to the nasal dorsum and nasal sidewalls. The nasal tip and alae should be avoided because necrosis is at a much higher risk. The use of soft-tissue fillers in the nose should be approached with caution.
A 21-year-old woman comes to the office for consultation regarding rhinoplasty. She says she is dissatisfied with the tip of her nose because it is “too big and wide.” Which of the following is the most effective suture technique to achieve a more refined triangular tip in this patient?
A) Columellar septal
B) Interdomal
C) Lateral crural mattress
D) Medial crural
E) Transdomal
The correct response is Option E.
The first suture for a broad, bulbous tip is the transdomal suture. This suture will narrow the dome and narrow the convexity of the lateral crus with mild increased tip projection. The interdomal suture is used mainly if there is asymmetry in domal height or to reduce the interdomal width.
The columellar septal suture is used to establish tip strength and integrity, which might have been lost with a transfixion incision. Lateral crural mattress sutures are used to create lateral crural concavity. Medial crural sutures or medial crural septal sutures are used to increase or decrease tip projection.
A 55-year-old woman comes to the office because she is dissatisfied with the appearance of her nose (shown), specifically the scars left by acne as a young adult. She has undergone scar revision by punch biopsy and closure as well as dermabrasion by four different physicians but has never been satisfied with the results. She spends approximately 1.5 hours per day putting makeup on her face before leaving the house. She has never married and feels embarrassed to be seen in public because she feels that everyone is staring at her nose. Which of the following most accurately represents the prevalence of this diagnosis in patients who undergo plastic surgery?
A) Less than 1%
B) 2 to 4%
C) 7 to 15%
D) 22 to 25%
The correct response is Option C.
The patient described has body dysmorphic disorder (BDD), which affects 7 to 15% of all plastic surgery patients. In this disorder, the patient’s degree of concern is far greater than the degree of actual deformity. This perception may involve the entire body or just one area. The patient is generally unaware that his or her concerns are excessive. BDD can be associated with other diagnoses, including depression, substance abuse, social phobia, and/or obsessive-compulsive disorder. The patient is preoccupied with his or her appearance so much that a significant amount of time is spent trying to camouflage or change the outward appearance with makeup. Most patients with BDD are single (70% never married), and up to 50% have suicidal ideation. Treatment involves referral to a psychiatrist where psychotherapy and pharmacotherapy are useful. Operating on these patients almost never leads to a satisfied patient; therefore, preoperative diagnosis is essential.
The prevalence of BDD has been shown to be significantly higher in the plastic surgery population than in the general population (1 to 3%). It does not appear to have a gender or cultural predilection.
The photographs shown above are of a 62-year-old man who sustained a nasal septal fracture in a high-speed motor vehicle collision five days ago. Following reduction of the fracture, which of the following grafts is most appropriate for correction of the deformity?
(A) Alloplastic graft
(B) Columellar strut graft
(C) Shield graft
(D) Spreader septal graft
(E) Umbrella graft
The correct response is Option D.
Fractures of the nose can occur in three zones. Fractures of the upper vault of the nose involve the nasal bones, ethmoid, vomer, and cephalic septal border. Fractures of the middle vault involve the upper lateral cartilages, septum, and maxilla. In patients with fractures of the lower vault of the nose, the alar cartilages and inferior septum are affected. This patient has fractures involving both the upper and middle vaults of the nose. Following reduction of the septum and nasal bones, spreader grafts should be inserted to provide support to the septum.
Compared with autologous tissues, alloplastic grafts have higher rates of exposure and infection and are relatively contraindicated in a patient with recent trauma to the nose and multiple mucoperichondrial lacerations.
Columellar strut, shield, and umbrella grafts are used for correction of deformities in the lower vault of the nose.
A 35-year-old woman presents 12 months following an open rhinoplasty for correction of an overprojecting tip, dorsal hump, and bulbous tip. No operative report is available. The patient reports an inability to breathe through the left nostril. On examination, the left lower lateral cartilage curves into the airway. No other abnormalities are noted. An illustration of a worm’s eye view of the patient’s nose is shown. Use of which of the following grafts is most likely to correct this patient’s breathing problem?
A) Alar rim graft
B) Columella strut
C) Lateral crural strut
D) Septal extension
E) Spreader graft
The correct response is Option C.
This patients breathing difficulty is due to the inward rotation and malposition of the left lateral crura, resulting in nasal airway obstruction. This malposition can occur following open rhinoplasty with division and/or mobilization of the lower lateral cartilage resulting in scarring and curvature. A lateral crural strut graft is a powerful technique that can be used to shape, reposition, or reconstruct the lower lateral cartilage. The graft is sutured between the undersurface of the lower lateral cartilage and the vestibular mucosa. This graft can extend into a subcutaneous pocket superficial to the pyriform aperture or a subcutaneous pocket in the alar rim.
The other choices will not reliably correct this lower lateral cartilage malposition.
A columella strut is used to support tip projection and position. A septal extension graft can more effectively support tip projection and position, as well as lengthen an overresected caudal septum.
Spreader grafts will improve a narrowed internal nasal valve. This patient has an external valve problem. It is possible that widening the internal nasal valve will improve airflow; however, it will not correct this patients anatomical obstruction and will widen the middle vault.
An alar rim graft is placed in a subcutaneous pocket along the alar rim edge. This graft will strengthen the external valve at the alar rim; however, it will neither straighten nor reposition the lower lateral cartilage out of the airway.
