KEY NOTES CHAPTER 9: AESTHETIC SURGERY - Rhinoplasty

Question 0

What is in the upper 1/3 of the nose?

Answer 0

Upper 1/3:

• paired nasal bones
• superiorly: nasal process of frontal bone
• laterally: frontal process of maxilla
• posteriorly: perpendicular plate of ethmoid

Question 1

Tell me about the anatomy of the nose.

Answer 1

Skin
Cartilage
Bone

Osseocartilaginous framework is divided into upper, middle and lower 1/3s.

Question 2

What is in the middle 1/3 of the nose?

Answer 2

Middle 1/3:

• upper lateral cartilages, dorsal cartilaginous septum (centre)
• keystone area: where nasal bones and upper lateral cartilages overlap.
• scroll area: where upper and lower lateral cartilages overlap.
• internal nasal valve: junction of upper lateral cartilage (caudal edge) and nasal septum. 10-15 degrees.

Question 3

What is in the lower 1/3 of the nose?

Answer 3

• lower lateral / alar cartilages: curved structures with apices.
• medial (columella), middle (tip) and lateral crus (superolateral).
• fibrous connections hold lower laterals to upper laterals and septum.
• external nasal valve formed by:
  + caudal edge of lateral crus,
  + soft tissue alae,
  + membranous septum,
  + nostril sill.

Question 4

Draw the nasal osseocartilaginous framework.

Answer 4

pg 554

Question 5

What does the septum consist of?

Answer 5

• anteriorly: quadrangular cartilage.
• superiorly: perpendicular plate of ethmoid.
• inferiorly: vomer.
• membranous septum and cartilaginous septum.

diagram pg 555

Question 6

What is the vascular supply of the nose?

Answer 6

.

Question 7

What is the sensory supply to the nose?

Answer 7

• skin: V1 & V2 of trigeminal
• radix: infratrochlear and supratrochlear nerves (V1)
• dorsum and tip: anterior ethmoidal nerve, external nasal branch (V1)
• lateral nose and tip: infraorbital nerve (V2)
• columella: nasal branch of anterior superior alveolar nerve (V2)

Question 8

What do these descriptive terms mean?

Tip-defining points.
Nasal length. 
Nasal projection.
Lobule.
Supratip.
Soft triangle.
Infratip lobule.
Open roof.
Outfracture.
Infracture.

Answer 8

(a) highest point of alar cartilages (light reflex).
(b) radix (nasofrontal angle) to nasal tip.
(c) nasal tip to nasla spine / alar-facial groove / subnasale.
(d) junction of upper and lower laterals to columella breakpoint, laterally to aka-lobule junction.
(e) just above domes of alar cartilages, between tip and dorsum.
(f) area of nostril rim without cartilage.
(g) from nasal tip to start of columella.
(h) gap between nasal bones and septum after dorsal hump is removed (before infracture).
(i) medial displacement of nasal bones to correct open-roof deformity or narrow base of nose.

Question 9

Rhinoplasty: History

Answer 9

• any problems breathing through nose?
• nose bleeds?
• allergic rhinitis?
• regular headaches?
• prior trauma or surgery to nose?
• profession depend on sense of smell?
• intranasal drug use e.g. cocaine?

Patient expectations:

• what do they not like about nose (specifics, beware patient who ‘hates my nose’ and not specific)
• do they understand the limitations of surgery?
• emotional and psychological state.

Question 10

Rhinoplasty: Examination.

Answer 10

Frontal view
- shape and proportions to face.
- skin quality: thin (irregularities more visible) vs sebaceous (difficult to see tip-work).
- symmetry, deviation
- width
- dorsal aesthetic lines
- nasal tip: bulbous, boxy, pinched, bifid, supratip break, tip-defining points.
alar rims, alar base width (medial canthus).
- dental occlusion, upper lip length.

Birds eye view
- straightness of dorsum.

Lateral view

• nasofrontal angle, nasal length, dorm, supra tip break, tip projection.
• maxilla: bony / soft tissue deficiency.
• lip-chin relationship.

Worms eye view

• nasal projection
• nostril symmetry.
• columellar: septal tilt, flared medial crura.
• alar base width.

Question 11

How do you assess the nasal airway?

Answer 11

Internal nasal valve: Cottle’s test (lateral traction to cheek and inhale).

External nasal valve

Thudichum nasal speculum examination:

• internal nasal valve collapse.
• inferior turbinate hypertrophy.
• septal deformities: deviation, tilt and perforation.
• septal cartilage for harvest.
• polyps, tumours.

Question 12

What are the advantages and disadvantages of open and closed rhinoplasties?

Answer 12

Closed (endonasal) approach

• no external scar.
• experience required, suited for minor hump reduction and tip correction.

Open approach

• full visualisation of nasal anatomy.
• transcolumellar scar, longer recovery for tip oedema.
• suited for extensive tip work, post-traumatic or revision rhinoplasty.

Question 13

What are the different types of incisions used?

Answer 13

Transcolumellar
- narrowest part, step or inverted V incision.

Infracartilaginous

• caudal edge of alar cartilage (hairline).
• continuation of trancolumellar in open rhino

Transcartilaginous = intracartilaginous

• closed rhino.
• incise through lateral crus of lower laterals, leaving 5-6mm caudally for support.
• can excise cranial portion to reshape.

Intercartilaginous
- between upper and lower laterals.

Transfixion incision
- incision in membranous septum, and between cartilaginous septum (sup) and medial crura of alar cartilages (inf).

Alar base excision
- to reduce nasal width.

Question 14

What can be done to alter the nasal skeleton?

Answer 14

Dorsal hump reduction: rasp or osteotome.

Infracture: osteotomy of nasal bones at base through intranasal or transcutaneous (postage stamp) incisions.

Osteotomies: lateral, medial, transverse, combination.

Aim: to narrow nasal vault or correct deviated nasal bones.

Question 15

Describe the different types of lateral osteotomies.

Answer 15

Low-to-high.

• for small open roof deformities.
• osteotomy from rim of pyriform aperture at nose cheek junction (adjacent to inferior turbinate) to just inferior to medial canthus at nasomaxillary suture.
• superior end of osteotomy is completed by pressing and greenstick fracture of bony vault.

Low-to-low.
- large open roof or broad nose.
- from pyriform aperture rim to just below medial canthus, closer to cheek than low-to-high.
+/- transverse osteotomy near medial canthus followed by infracture.

Double level.

• very large open roof / broad nose.
• medial osteotomy along nasomaxillary suture.
• low-to low osteotomy
• transverse osteotomy to complete superior fracture line.

Question 16

What techniques are available for dorsal augmentation?

Answer 16

Aim:

• correct lack of tip projection, nasal length and dorsal height.
• camouflage contour irregularities, saddle nose deformity.

Onlay grafts

• cartilage graft
• morcelised cartilage wrapped in Surgicel (Turkish delight technique)
• split calvarial bone graft
• ADM

Alloplastic implantation

• e.g. dorsal-columellar L strut.
• complications: implant displacement, prominence, haemorrhage, supratip deformity, extrusion (0.5%)

Question 17

How is the nasal tip corrected?

Answer 17

1. Resection of alar cartilage.
2. Insertion of cartilage grafts.
3. Suture techniques.
4. Depressor septi nasi division.

Question 18

Tell me about alar cartilage resection.

Answer 18

Cephalic trim of middle and lateral crura, leaving 6mm caudal strip for support.

• Refines bulbous or boxy tip.
• Medialises tip-defining points.
• Increases tip rotation.

Question 19

Tell me about cartilage grafts:

Answer 19

1. Tip grafts
   - shield = onlay graft to increase projection, shape tip, disguise irregularities.
   - cap = to fill tip clefting.
   - columellar strut = cartilage strip between medial crura and rests on anterior nasal spine to maintain tip projection.
   - umbrella = onlay + columellar strut.
2. Spreader grafts.
   - matchstick cartilage grafts between nasal septum and upper laterals to correct internal nasal valving.

Question 20

What different tip-suturing techniques do you know?

Answer 20

1. Medial crural fixation suture: between medial crura of each alar cartilage, also sutures columellar strut graft.
2. Transdomal: (each dome) narrows tip
3. Interdomal: (both domes) narrows tip and clefting.
4. Columella-septal: treats hanging columella, improves tip projection and rotation.

Question 21

What does the depressor septi nasi do and where does it originate and insert?

Answer 21

Origin: orbicularis oris / periosteum midline of upper lip.
Insertion: footplates of medial crura.

• Causes tip droop, shortened upper lip and transverse philtral crease.

Division: at origin from mucosa side near upper lip frenulum.

Question 22

Tell me your technique for rhinoplasty: open.

Answer 22

.

Question 23

What are the early complications of rhinoplasty?

Answer 23

1.7-18%
Most common: bleeding, infection, nasal airway obstruction, deformities.

Immediate

• excessive bleeding, mucoperichondrial tears (-> septal perforation)
• fracture of septal L strut -> loss of dorsal nasal and tip support,
• buttonholing skin.

Early

• epistaxis,
• septal haematoma,
• infection,
• wound dehiscence,
• skin necrosis,
• CSF leak,
• olfactory disturbance,
• numbness upper incisors.

Question 24

What are the late complications of rhinoplasty?

Answer 24

Late:
Deformities:
- Deviation,
- Asymmetry,
- Inverted V deformity (visible caudal nasal bones after dorsal reduction when upper lateral cartilages collapse inferomedially).
- Rocker deformity: when osteotomy is too cranial (above medial canthus) and see-saws out. Treatment: redo transverse osteotomy more caudally.
- Polly beak deformity: loss of supra tip break and tip ptosis.

Intranasal synechiae.
Vestibular stenosis.
Septal perforation.
Nasal valve collapse.
Graft migration / extrusion.
Prolonged oedema.
Under / over-correction of patient's perceived deformity.