19 Closed technique rhinoplasty
Rhinoplasty is uniquely difficult and uniquely rewarding surgery. The very fact that surgeons calculate and publish their nasal surgery revision rates (a practice uncommon in other aesthetic procedures) distinguishes the diminutive “nose job” as an operation that can accomplish harm as well as good, producing favorable or highly unfavorable results. Some excellent surgeons stop performing rhinoplasty, with great relief; others abandon it early in their careers after unsuccessful attempts to produce the desired results. This need not be the case. The goal of this chapter is to outline a system of understanding and treating nasal deformities that is based on functional analysis, knowledge of critical anatomical variants, soft tissue and skeletal behavior, and careful, logical surgical technique.
The advocates of the open approach argue that rhinoplasty (especially endonasal rhinoplasty) is difficult because the surgeon does not have good binocular vision through small incisions, the dissection is blind, the anatomy is complex, and the operation is technically difficult.
There is a small amount of truth in each of those statements – but the same can be said of many plastic surgical operations. Actually, rhinoplasty is primarily difficult because the nasal soft tissues have limited contractility; the nasal regions are structurally and functionally interrelated, not independent; the operation is dynamic and interactive; and because rhinoplasty is a right brain operation.
Modern rhinoplasty is not simply the reduction rhinoplasty model to which grafts have been added; viewed only in that way, current techniques will seem unnecessarily convoluted. Instead, a new rhinoplasty paradigm has emerged in which nasal skin is recognized to be more fixed than variable; in which aesthetics, proportion, and function depend on structural interdependencies and skeletal balance; and in which rhinoplasty therefore becomes an operation of reduction, augmentation, and equilibration. In turn, the new paradigm has widened the spectrum of surgical problems that may be solved. Rhinoplasty remains difficult, but becomes easier when viewed in the context of a model that considers both function and aesthetics and prescribes techniques that effectively modify them together.
Rhinoplasty is probably the most right-brain operation that plastic surgeons perform.1 Unfortunately, our educational system cultivates the verbal, rational, analytical, and numerical left side of the brain, tending to ignore the right side. This is one of the reasons that most adults draw with the same level of sophistication that they possessed as a 10-year-old child, which is, not coincidentally, the age at which the left brain becomes dominant. The ease with which surgeons can perform rhinoplasty correlates directly with the facility with which they can deliberately involve right-brain function.
The most attractive noses in nature do not look assembled but unified as a whole, in which every part seems to belong. This principle should also apply to rhinoplasty results. The beauty of the assembled result, the finished surgical product, depends on the ability to see the preoperative excesses and deficiencies in shape and proportion as they really are, with no preconceptions; balance them against the patient’s surgical goals; and from those accurate observations create an effective surgical plan. The most direct means to this kind of analysis involves significant right-brain contributions. Right brain function can be cultivated2 by analytic exercises and by studying silhouettes of patient profiles.1
The fact that many post-rhinoplasty nasal configurations, and all “end-stage” noses, look the same, is not a coincidence. The response of any nasal skeleton and its investing soft tissues to reduction is not idiosyncratic but consistent and therefore predictable.3,4 These forces collapse the upper nose caudally and medially over the pyramidal bony and upper cartilaginous vaults, cephalad at the columella, posteriorly over the maxillary arch, and posteriorly and concentrically around the tip lobule (Fig. 19.1). Whether the nasal skeleton has been reduced by surgery, trauma, congenital anomalies, or Wegener’s granulomatosis, the essential external appearance remains the same. Variations occur because of disequilibrium between skeletal and soft tissue volumes or differences in soft tissue thickness and elasticity, not because biologic forces differ from patient to patient.
If the reaction of the nose to reduction rhinoplasty is not idiosyncratic but predictable, it follows that the surgeon who can predict the nasal response to certain interventions can control the result. Useful here is the concept of a dynamic equilibrium,3 in which preoperative nasal shape represents not a static structure but rather a dynamic equilibrium, the sum of balanced, opposing forces between the nasal soft tissues and their underlying support. At the start of a rhinoplasty, the nose is equilibrated. Skeletal reduction during rhinoplasty disrupts this preoperative skeletal and soft tissue equilibrium; the nose in disequilibrium at the conclusion of a rhinoplasty cannot remain the same. Soft tissue and skeletal contraction occurs until the nose re-establishes its internal equilibrium or until contraction can no longer occur. The degree of disequilibrium at the end of the procedure thus determines the amount of redraping and contraction that will occur postoperatively: the bigger the disequilibrium, the bigger the postoperative surprise. The surgeon therefore ideally controls the postoperative equilibrium by permitting soft tissue contraction only where it is most predictable (e.g., over the bony and cartilaginous dorsa) and by minimizing contraction where it is less predictable (e.g., the lower nasal third). In doing so, the surgeon immediately gains a powerful tool for influencing postoperative nasal contour.
In understanding structural nasal interrelationships, it is helpful to conceptualize the nose as a system of two interrelated layers (Fig. 19.2). The outer layer, like a soft, elastic sleeve, slides over the inner semi-rigid layer and contains the entire investing nasal soft tissues plus the alar cartilages and their associated lining. The inner layer contains everything else (the bony and upper cartilaginous vaults, the nasal septum, and their associated linings). This two-layer concept associates those structures that behave together anatomically and functionally, and provides an explanation for the “global” manifestations of some surgical changes (e.g., the effect of dorsal reduction or augmentation on nasal length).5
Fig. 19.2 The structural layers of the nose, which separate those anatomical units that move together. The investing soft tissues and alar cartilages glide over the inner, fixed, semirigid layer, which contains the bony vault, the upper cartilaginous vault, and the nasal septum.
The width and stability of the upper cartilaginous vault (formed by the upper lateral cartilages and the anterior septal edge), the critical area of the internal nasal valves, depend not only on the width of the bony vault but also on the height and width of the middle vault roof.6 Resection of the middle vault roof during hump reduction removes this most critical anterior stabilizing force on the upper lateral cartilages, which will fall medially and produce a characteristic “inverted V” deformity and consequent narrowing at the internal valves.7 Middle vault collapse virtually always occurs when the cartilaginous roof has been resected, whether or not osteotomy has been performed, but may not be visible if the overlying soft tissues are sufficiently thick; when the nasal skin is thin, the deformity can be impressive (Fig. 19.3). To avoid middle vault collapse and internal valvular incompetence, the surgeon should plan to reconstruct the normal distracting forces by a substantial dorsal graft or by spreader grafts,8,9 which provide the same degree of functional mean nasal airflow improvement (see below).
Fig. 19.3 The characteristic appearance caused by resection of the roof of the middle vault, which produces the so-called inverted V deformity and internal valvular incompetence. The most effective corrections are spreader or dorsal grafts.
(From Constantian MB. The middorsal notch: an intraoperative guide to overresection in secondary rhinoplasty. Plast Reconstr Surg. 1993; 91:477.)
The upper lateral cartilages are supported caudally by their relationship to the cephalic margins of the lateral crura in the region of the so-called ‘scroll’; radical alar cartilage resection can compromise middle vault support and may leave an external deformity typified by deepening and lengthening of the alar creases. Resect the upper lateral cartilages submucosally only when failure to do so would allow them to prolapse into the airway or when necessary to shorten the nose.
The point of intersection of the upper and lower lateral cartilages creates the “watershed” area between the internal and external nasal valves, and aggressive surgery in this area also affects external valvular competence, particularly in patients whose alar cartilage lateral crura are cephalically rotated.9,10 Compared with caudal support of the upper lateral cartilages, however, anterior support provided by the intact cartilaginous roof is more profound and more critical to airway function.
Tip projection, that is, the intrinsic ability of the alar cartilages to support the tip lobule independent of dorsal height, depends on alar cartilage middle crural size, shape, and substance (Fig. 19.4). Tip projection extremes are the easiest to identify. The nasal tip in Figure 19.4A depends not on bridge height but on intrinsic alar cartilage strength and projection. Conversely, the nasal tip in Figure 19.4B is partially dependent on bridge height; therefore, tip projection will decrease when the dorsum is resected. It is important to identify inadequate tip projection preoperatively so that its correction can be incorporated in the surgical plan; inadequate tip projection cannot be rendered adequate by bridge resection alone. The tip, the lower nasal skin, and in many patients nearly the lower half of the profile line depend on suspension of the skin sleeve by the alar cartilages, which, like a “cap” anterior to the remaining skeleton, maintain lower nasal tension. The alar cartilages carry a larger responsibility for caudal nasal support than may at first be evident.
(B from Constantian MB. Distant effects of dorsal and tip grafting in rhinoplasty. Plast Reconstr Surg. 1992; 90:405.)
A great deal can be learned about primary rhinoplasty by observing the deformities of secondary rhinoplasty patients seen in consultation and by examining one’s own unsatisfactory results. A retrospective study of 150 consecutive secondary rhinoplasty and 50 primary rhinoplasty patients suggests that only four anatomic variants in the primary nose particularly predispose to unfavorable rhinoplasty results: low radix/low dorsum, narrow middle vault, inadequate tip projection, and alar cartilage malposition.11
Low radix or low dorsum begins caudal to the level of the upper lash margin with the patient’s eyes in primary gaze; this variant was present in 93% of the secondary patients and 32% of the primary patients in the series.11 First described by Sheen, the low radix is one of several primary causes of nasal imbalance: an upper nose that seems too small for its lower nasal component.12 When the radix begins lower than the upper lash margin, dorsal length is therefore shorter and so nasal base size appears larger. The classic imbalance may take the form of the depression or notch in the upper nasal third, or a low, straight dorsum may accompany a large nasal base. Whether or not the patient has a dorsal convexity, the surgeon often hears the same complaint: “The tip of my nose sticks out too far.” The surgical dilemma is as follows: If the surgeon reduces the nasal dorsum, the patient’s preoperative skeletal and skin sleeve maldistribution will worsen: the lower nose will appear even larger. The surgeon fortunately has two other choices: either limit tip reduction or raise the dorsum segmentally or entirely to balance the nasal base. Variations of the latter option are generally safer because they require less contraction of the thicker nasal base tissues.
A narrow middle vault (Fig. 19.5) is arbitrarily defined as any upper cartilaginous vault that is at least 25% narrower than the upper or lower nasal third (present in 87% of the secondary patients and 38% of the primary patients in this series). This variant was described by Sheen in conjunction with short nasal bones13 but has been discussed subsequently by that author and others11,14–16 as a trait that places the patient at special risk for internal valvular obstruction, which can exist preoperatively or may be produced by dorsal resection. Descriptions of valvular collapse had appeared earlier in the rhinoplasty literature17–19 but the missing puzzle piece had been the link between resection of the cartilaginous roof and postoperative internal valvular collapse, a phenomenon previously attributed to traumatic or surgical avulsion of the upper lateral cartilages from the nasal bones. Resection of even 2 mm of the cartilaginous roof during hump removal ablates the stabilizing confluence that braces the middle vault, 80 which can now collapse toward the anterior septal edge, restricting airflow at the internal valves and producing a characteristic inverted “V deformity”. Rhinomanometric studies indicate that valvular obstruction is 4 times more common than pure septal obstruction in primary rhinoplasty patients and 12 times more common in secondary patients; reconstruction of incompetent, internal valves by dorsal or spreader graft doubles nasal airflow in most patients.8,20
Fig. 19.5 Narrow middle vault treated with spreader grafts. Many of these patients have preoperative internal valvular incompetence and will develop increased airway obstruction after resection of the cartilaginous roof.
(From Constantian MB. Experience with a three-point method for planning rhinoplasty. Ann Plast Surg. 1993; 30:1.)
A tip with inadequate projection is defined as any tip that does not project to the level of the anterior septal angle. Inadequate tip projection was present in 80% of the secondary patients and 31% of the primary patients in the reported series.11 Despite its common use and importance, the term “tip projection” has been used to connote different things by different authors. Some surgeons assess tip projection by measuring the distance of the most projecting point of the tip from a facial parameter,21,22 and others by the relative proportion of the nasal base segments anterior and posterior to the upper lip23,24 or the relative lengths of the nasal base and upper lip.25 Although these definitions apply in some cases, there are patients whose nasal bases are large but whose tip cartilages are nevertheless poorly projecting (i.e., reflecting a disproportionate amount of lower nasal skin, rather than excessive cartilage size). In these individuals, tip projection may be inaccurately assessed as “adequate” or even “excessive”, even though the alar cartilages still lack the substance required to create a straight bridge line.
An alternative functional definition of tip projection is the relationship of the tip lobule to the anterior septal angle. Alar cartilages sufficiently strong to support the tip to the level of the septal angle are “adequately projecting” (Fig. 19.4A); alar cartilages too weak to do so are “inadequately projecting” (Fig. 19.4B). The practical value of this definition lies in its ability to define treatment: adequately projecting tips do not need increased support, whereas inadequately projecting tips do. Further, by defining tip projection relative to the septal angle, the surgeon can distinguish between two associated but distinct entities: (1) intrinsic anterior supporting strength supplied by the alar cartilages and (2) skin sleeve volume and distribution in the lower nasal third. Inadequately projecting nasal tips often appear to “hang” from the septal angle (Fig. 19.4B). Because an inadequately projecting tip owes its position to dorsal height and not only to tip cartilage support, the surgeon must employ some tip-strengthening method (sutures, struts, or grafts) to create that support. A straight dorsum requires the nasal tip to support itself independent of bridge height; that is, to be adequately projecting. Interestingly, rhinoplasty pioneer Jacques Joseph instinctively solved the problem of inadequate tip resection in his patients by limiting bridge resection and deliberately leaving a dorsal convexity.26
“Alar cartilage malposition” describes cephalically-rotated lateral crura whose long axes run on an axis toward the medial canthi instead of toward the lateral canthi, the position of orthotopic lateral crura (Fig. 19.6). This anatomic variation was first recognized by Sheen27 as an aesthetic deformity that produced a round or boxy tip lobule with characteristic “parentheses” on frontal view. Initially believed to be a rare variant, malposition is present in approximately 50% of primary patients and 80% of secondary patients.28 Malposition also has two additional ramifications that are not aesthetic. First, the abnormal cephalic position of the lateral crura places them at special risk if an intercartilaginous incision is made at its normal intranasal location.10 This maneuver could transect the entire rotated lateral crus instead of only splitting the intended cephalic portion: the entire lateral crus may thus be inadvertently removed. Resected or whole, most malpositioned lateral crura do not provide adequate external valvular support, and so malposition is not only associated with boxy or ball tips but also the leading cause of external valvular incompetence.20 The secondary deformity is characteristic.
Fig. 19.6 Patient with alar cartilage malposition (as well as low radix, narrow middle vault, and inadequate tip projection) (A) preoperatively and (B) after primary rhinoplasty. (C) Quiet and (D) forced inspiration demonstrate incompetence of the internal and external nasal valves. (E–H) After dorsal, spreader, tip, and alar wall grafts. Postoperative airflow typically triples or quadruples in such patients.
The adequate treatment of cephalic rotation of the lateral crura requires resection and replacement of these structures, relocation of the lateral crura to support the external valves, or supporting the areas of external valvular collapse with autogenous grafts.29 Prior reports have indicated that approximately 50% of patients presenting with external valvular obstruction have alar cartilage malposition. Correction of external valvular incompetence doubles mean nasal airflow in most patients (2.5 times for primary patients; 4.0 times for secondary patients).8
None of these four anatomical variants (low radix or low dorsum, narrow middle vault, inadequate tip projection, and alar cartilage malposition) always requires treatment. For example, the low radix must always be assessed relative to nasal base size: if the base is small, a low radix may create the best balance. But they do supply cautionary notes. At least one of these four anatomic traits was present in each of the 150 secondary patients in the reported series.11 Some 78% of the secondary patients and 58% of the primary patients had three or all four of the traits. The most common grouping in both primary and secondary patients was the triad of low radix, narrow middle vault, and inadequate tip projection (40% and 28%, respectively) (Fig. 19.7). The second most common grouping was the association of all four anatomic traits (27% of secondary and 28% of primary patients). None of these anatomic variants is adequately treated by classic reduction rhinoplasty, emphasizing the importance of careful preoperative diagnosis.
Fig. 19.7 The most common grouping of the four anatomic variants that predispose to unfavourable results; low radix, narrow middle vault, and inadequate tip projection. (A) Preoperative view. (B) 1 year postoperative frontal. (C) Preoperative view and (D) 1 year postoperative oblique view (now symmetric). (E) Schematic of the surgical correction, involving dorsal reduction; conservative reductions of the lateral crura and caudal upper lateral cartilages; maxillary augmentation; and radix, spreader, and tip grafts with left unilateral osteotomy.
(From Constantian MB. Elaboration of an alternative, segmental, cartilage sparing tip graft technique: experience in 405 cases. Plast Reconstr Surg. 1999; 103:237.)
Although many patients with obstructed nasal airways undoubtedly improve after septoplasty or submucous septal resection with or without inferior turbinectomy, not all do. Adding to the frustration of patient and surgeon are three other common observations: that there is often a poor correlation between a patient’s symptoms and the apparent site of clinical septal or turbinate obstruction; 18–21 that patients frequently breathe better (preoperatively and even postoperatively) on the “narrower” side (ipsilateral to the septal deviation); and that many patients who have undergone prior successful septoplasty and turbinectomy or who have straight, unoperated nasal septa still complain of airway obstruction.
These apparently inconsistent observations are more understandable if the reader considers airway size to be the product of at least four factors: (1) mucosal sensitivity to the environment or hereditary factors; (2) inferior turbinate hypertrophy from many causes; (3) septal deviation; and (4) position and stability of the lateral nasal wall during the dynamic process of ventilation.8,9,20 Thus, any congenital or acquired weakness or instability of the upper or lower lateral cartilages or their investing soft tissues (which compose the internal and external nasal valves, respectively), along with septal and inferior turbinate size and position, becomes a factor that may profoundly influence the ability to draw adequate volumes of air through the nose.
The internal nasal valve is formed by the articulation of the caudal and anterior (or dorsal) edges of the upper lateral cartilages with the anterior septal edge (Fig. 19.8); the external nasal valve is composed of the cutaneous and skeletal support of the mobile alar wall (the alar cartilage lateral crura with their associated external and vestibular skin coverings). The watershed area between the valves occurs at the transverse portion of the alar crease and at the articulation of the caudal edge of the upper lateral cartilages with the alar cartilage lateral crura.
Fig. 19.8 The nasal valves. The internal valves are formed by the articulation of the upper lateral cartilages with the anterior (dorsal) septal edge; the external valves are formed by the alar cartilage lateral crura and their associated investing soft tissue cover.
Until recently, efforts to correlate nasal airflow with clinical symptoms had yielded equivocal conclusions. There was argument on both clinical and rhinomanometric grounds that septoplasty either did or did not improve nasal airflow.30–34 For such a commonly and easily diagnosed clinical problem as septal deviation, one would expect to find more unanimity in clinical series. These observations were clouded further by the fact that some 80% of nasal septa in the population at large are “deviated”, and by imprecision in distinguishing internal from external valvular incompetence. Nevertheless, mounting clinical evidence indicates that obstruction at either set of valves may profoundly obstruct the airway, even in the absence of septal deviation.35–58
Adding to the confusion, is the absence of consensus in the literature about whether rhinoplasty itself impairs airflow, which is surprising in view of the number of patients who have postoperative airway obstruction. In fact, the second most common cause for malpractice litigation after rhinoplasty is unrelieved or new nasal airway obstruction (M. Gorney, pers comm, March 2000).
To help resolve some of these conflicting clinical observations and to provide quantitative measurements of the relative increases in nasal airflow after functional septal or valvular surgery, an ongoing study of 600 consecutive patients undergoing surgery for airway obstruction was undertaken between 1991 and 2008.8,59 Patients with septal perforation, atopic patients, and patients requiring turbinectomy were excluded. The diagnosis of septal obstruction or valvular incompetence was made by observation of the nasal airway and nasal sidewall movement with and without a nasal speculum during quiet and forced inspiration (Fig. 19.9). When a flaccid or collapsible valve was supported during inspiration by a cotton-tipped applicator, the patient could usually appreciate an immediate improvement in nasal airflow, thus directing the surgeon toward appropriate operative treatment. Septoplasty and valvular reconstruction by cartilage or bone grafts were performed as indicated. Anterior, active, mask rhinomanometry was performed according to the method of Mertz et al.42,60–62
Fig. 19.9 The common “straight line” strategy used to plan rhinoplasty. The assumptions implicit here are that the skin sleeve will contract infinitely and uniformly to any skeletal size and shape, and that dorsal and tip resections will affect only those structures. The ideas are all very logical; they are just not true.
That study comprised 600 patients: 78% women and 22% men; 36% primary rhinoplasties and 64% secondary rhinoplasties (median follow-up 14.3 months, mean 27 months). The longer-term data of 362 patients observed for a minimum of 12 months (median 29 months) supported the numbers in the entire group.
7. Septoplasty in addition to valvular reconstruction did not significantly improve nasal airflow over the results obtained by valvular reconstruction alone, even in patients observed more than 100 months postoperatively.
10. Of the 384 secondary rhinoplasty patients, 94% had previously undergone an adequate septoplasty but were still symptomatically obstructed. Within this group, valvular reconstruction alone corrected the airway in 97% after one operative procedure.
11. When primary and secondary rhinoplasty patients were stratified, the improvement in primary patients equaled or exceeded the improvement achieved in secondary rhinoplasty patients in six of the eight obstructed sites examined.
13. When the entire 600-patient group was stratified, the greatest improvement was observed in those patients observed more than 12 months, supporting the view that the airway continues to enlarge as edema resolves.
In conclusion, current rhinomanometric data support the concept that lateral nasal wall movement caudal to the bony arch (containing both the internal and external valves) constitutes a cause of airway obstruction equal to or greater than septal deviation in many rhinoplasty patients. By visualizing the airway as a structure in which the septal partition forms one side and the mobile lateral nasal wall forms the other, and in which the turbinates and mucosa function as additional dynamic structures, the inconsistencies in prior clinical observations become easier to explain. Inspired airflow passes through the nose at 15–65 km/h, the latter equivalent to gale force winds.63 The size of any nasal airway thus depends not only on the position and configuration of the septum and turbinates but also on the stability and competence of the nasal valves under significant transmural pressures. The observation that patients often breathe worse on the side contralateral to the septal obstruction (45% of our patients with lateralized obstructions) can therefore be explained through valvular incompetence. In patients with septal deviation and valvular incompetence, the side with the greater airflow and greater transmural pressure (i.e., the side contralateral to the septal deviation) will collapse first and therefore become more symptomatic.
This study did not answer the question of where turbinates fit into the hierarchy of nasal obstructions. In atopic individuals with gross turbinate hypertrophy or polyps, turbinectomy is unquestionably valuable.64 However, the mean nasal airflow improvements listed above were achieved without turbinectomy, even in a population of patients with secondary deformities, valvular incompetence, prior intranasal scars, webs, or vestibular atresia, suggesting that turbinate obstruction in many patients may be largely reactive or secondary and that radical turbinectomy may not often be necessary if septal and valvular factors have been addressed properly.
If the nose is being reduced, the entire surgical result depends on the validity of this assumption. The nasal skin sleeve does contract according to its quality, thickness, and preoperative distribution, but not necessarily to the shape of the surgically reduced skeleton. The vectors of skin sleeve contraction are related to, but independent of, the volume and contour of the underlying skeleton; the end stage of these vectors is the classic shape of supratip deformity (Fig. 19.1). If this assumption was always true, supratip deformity would never occur and augmentation would not correct it.65
The classic application of this assumption is a preoperative plan in which the surgeon plans to resect all nasal dorsum anterior to a straight line drawn from the nasal radix to the point of the tip (Fig. 19.9). Underlying this strategy is the assumption that dorsal reduction affects bridge height alone. Changes in the nasal skeleton are not independent, however, but rather have global effects outside their areas. Resection of the nasal bridge affects nasal width and length, apparent nasal base size, middle vault support, alar rim contour, and columellar position. Similarly, alar cartilage reduction can affect tip support and projection, nasal length, alar rim contour, and external valvular support. These structural interdependencies are not just regional. Recognizing them is necessary to preoperative planning, interpretation of intraoperative nasal appearance, postoperative success, and the correction of secondary deformities.
Although rhinoplasty presents unique difficulties for the surgeon, it is difficult for the patients as well. Those surgeons who have seen secondary rhinoplasty candidates devastated by the results of one or more prior operations should immediately recognize the importance of a safe and biologically sound surgical plan and of an accurate understanding between patient and surgeon of the aesthetic goals and the realities of the surgical problem – that is, what is possible and what is not.
Making the interview more difficult is the prevalent misconception that many patients hold about their nasal deformities and therefore about the corrective plan. Many patients do not recognize that a simple nasal reduction may not achieve their goals. Patients without airway obstruction do not appreciate the importance of maintaining nasal function, and most do not realize that an improperly performed rhinoplasty can jeopardize the airway.
The patient must therefore be guided to understand that every rhinoplasty is a compromise between the patient’s preferred aesthetic goals and the limitations that a predetermined preoperative skeletal and soft tissue configuration imposes. Donor materials vary in quantity, character, and composition, determining their usefulness.66 Finally, many preoperative noses already have some desirable features; patient and surgeon should be careful not to destroy them.
It is important to elicit the patient’s goals in the greatest possible detail and to prioritize them. Is the major issue bridge height, tip projection, nasal length, asymmetry, or airway? How long has the sense of deformity existed? This latter question is more critical in older than in younger patients: the 60-year-old patient who has disliked her nasal shape for 40 years may tolerate a larger change than will one who has been troubled for only 5 years and who may be noticing only signs of recent aging.
For any patient older than 14 years, the author prefers to interview and examine the patient alone (in minors after parental permission), before involving the family, spouse, or others of significance in the discussion. Although some protective family members or spouses initially object to this policy, it is important to establish an individual relationship with the patient and to hear his or her concerns and complaints free of outside influences. Not surprisingly, it is usually the family members who object most strongly who should most be excluded from the initial consultation, when their presence invariably distracts the patient, and questions to the patient (like some odd ventriloquist act) elicit responses from the family member instead. If, after an adequate explanation, the patient’s family will not accept an initial interview with the patient alone (which occasionally happens), their response is a significant sign that should not be overlooked.
When the patient has had prior surgery, it is important to obtain a careful chronology and, if possible, photographs that reflect the preoperative appearance. Such pictures provide information about the prior surgeon’s goal and how the current deformities may have occurred and place the patient’s original objectives in current perspective. For the younger surgeon, a comparison of preoperative photographs to outcomes is invaluable and teaches an enormous amount about the consistencies and variabilities of nasal skeletal and soft tissue responses to surgery.
Inquire about the airway first to avoid becoming distracted by the patient’s aesthetic considerations, which always seem more pressing. Ask about periodic or cyclic airway obstruction; which airway is worse; any history of nasal trauma; seasonal allergies that obstruct the airway; clear rhinitis; episodes of suppurative sinusitis requiring antibiotics; snoring, epistaxis, and sinus headache; and what nonsurgical remedies the patient has previously tried, successfully or unsuccessfully. Not infrequently, secondary rhinoplasty patients with poor airways chronically self-medicate with steroid or vasoconstrictive sprays that must be eliminated before surgery. Also important are the patient’s work environment and a history of tobacco or alcohol consumption (either of which may cause nasal congestion) and, more important now than in previous years, cocaine use. Finally, inquire about any nasal areas that the patient does not wish altered and, if appropriate, whether a change in ethnic appearance is desired.
Primary and secondary rhinoplasty patients differ in three characteristic ways. First, the secondary patient’s scarred, contracted soft tissues will not tolerate aggressive dissection, multiple incisions, or tight dressings. Second, graft donor sites may have already been harvested, necessitating the use of more difficult (distorted septum or concha), painful (costal), or frightening (calvarial) donor sources. Third, the secondary rhinoplasty patient’s morale is often more fragile. Having already invested money, time, discomfort, and emotion in one or more unsuccessful procedures, what secondary rhinoplasty patients fear most and need least are additional disappointments. The surgeon should be careful to construct a plan that is based on a clear understanding of what is possible and founded on sound surgical and biologic principles that maximize the airway and respect the patient’s aesthetic goals.67
It is wise to make a habit of examining the internal nose first, so that this most critical functional area is not forgotten in the discussion of aesthetics. Patients are always grateful to breathe well, even when an inadequate airway is not a prominent preoperative complaint; patients who breathe poorly may be unaware of their obstructions. The surgeon must avoid unintentionally decreasing postoperative nasal function; this occurs more often than is often recognized and poor airways frequently dominate the complaints of secondary rhinoplasty patients. The internal nose should be examined without manipulating the airway by asking the patient to breathe deeply and observing areas of collapse or asymmetry in the nasal sidewalls, high septal deviations, distortion of the columella, protrusion of the caudal septum, or alar rim collapse.
Sidewall collapse with inspiration at one or both of the nasal valves is surprisingly common. It is important to determine why valvular incompetence exists (e.g., prior surgery, intrinsic weakness, or alar cartilage malposition). If sidewall collapse occurs, occlude one nostril and ask the patient to compare flow through the unobstructed airway with and without supporting the collapsing area with a cotton-tipped applicator soaked in 1% Pontocaine hydrochloride for the patient’s comfort. Patients with valvular incompetence will notice an obvious and gratifying increase in airway size. The surgeon may observe valvular collapse and substantial airway obstruction, even in the patient with a straight, unoperated septum and without turbinate hypertrophy. Here, septoplasty may be indicated to harvest grafts but by itself will not open the airway; the surgeon must also place appropriate valvular grafts. Reconstruction of the internal and external valves can triple or quadruple airflow in most rhinoplasty patients, even when septoplasty is not simultaneously performed.8
The septum should be palpated for substance, contour, and mucosal cover (indicating the sequelae of allergy, injury, perforation, or chronic cocaine use). It is also important to assess whether a “high” (i.e., toward the anterior edge) septal deviation exists; because hump removal can unmask a high septal curvature, the surgeon should be prepared to camouflage or correct the septal deflection with unilateral or asymmetrically thick spreader grafts.14,68
Although the turbinates are time-honored causes of airway obstruction and affect the airways of atopic patients or patients with chronic, severe septal deflection (in which the turbinate contralateral to the septal deviation hypertrophies), clinical and rhinomanometric data indicate that obstructing turbinates are relatively low in the hierarchy of common airway obstruction causes in primary and secondary patients. Because turbinates warm and humidify inspired air, the surgeon should plan conservative resections even in atopic patients. Furthermore, histologic studies have shown that turbinate hypertrophy secondary to septal deviation is characterized by bony, not mucosal overgrowth.69 Therefore, most patients who have had good septal and valvular reconstruction can be adequately treated by only turbinate crushing and outfracture (or no treatment at all).70
Palpation of the external nose provides important information about cartilaginous size and substance, bony vault length, nasal sidewall stiffness (another assessment of valvular support), and soft tissue thickness. Tip lobular contour is considered, as is the balance between nasal base size and bridge height (see below). The patient is asked to discuss each nasal area, whether or not it has been mentioned previously: width, length, bridge contour, tip shape, nostril size, columellar and upper lip position, and any asymmetries.
On frontal view, the upper nose should be narrower than the lower nose; symmetric, confluent, divergent lines should connect the two. On oblique view, there should be no regional discontinuities, the supratip should be flat, and tip lobular mass should fall below the levels of the peaks of the alar cartilage domes. On lateral and oblique views, nasal length and base size should balance each other. Ideal parameters have been suggested.71–75 The practical difficulty in employing many of these guidelines lies largely in the facts that skin sleeve volume and distribution have already been predetermined and that skin contractility is limited, not infinite. Furthermore, ideal aesthetics do not apply to most patients, even most Caucasians.75 If the surgeon had the latitude of reducing skin volume, the size of the postoperative nose could be altered more radically to a patient’s facial measurements, body habitus, or other parameters. In practice, however, the surgeon works within narrower limits. The airway should be patent and stable on forced inspiration. Beyond these basics, the details depend on the patient’s skeletal framework and soft tissue cover and his or her aesthetic goals. Rhinoplasty offers, as much as or more than any other aesthetic procedure, the possibility of individualizing an aesthetic goal.
For consultation, formulation of an operative plan, and intraoperative guidance, good photographs are imperative. The patient’s photographs should be available before the immediate preoperative visit so that the operative plan on which surgeon and patient have already agreed may be reviewed or modified. Photographs should include full head and close-up frontal views, both oblique views (which often differ, particularly in patients with nasal asymmetry), both lateral views, and an inferior view. Photographs are best taken with a portrait focal length lens (90–105 mm) against a medium–dark background, lit so that symmetries and contours will be depicted accurately. Camera-mounted flash units are inferior to studio systems with umbrella lights or wall-mounted strobes to provide backlighting and to illuminate the face and hair.
Because practical rhinoplasty strategies may differ from what patients imagine, the patient must understand the logic of the surgeon’s plan and prefer it to other reasonable alternatives. Unless the surgeon plans only to reduce the nose, he or she must help the patient understand the benefits of equilibrium or conservative reduction; to this end, words like “balance” and “proportion” often serve better than terms that signify only size. It is best to be specific about the plan down to the last graft and choice of donor sites; this candor places patient and surgeon on the same side of the problem and also ensures that minor postoperative imperfections are more likely to be tolerated by the patient, who understood the necessity of each surgical maneuver beforehand. Recognizing the rationale for grafting is more difficult for primary than for secondary patients; the latter, who have already seen the effects of reduction and disequilibrium on their nasal configurations and airways, are often easier to convince.
Patient and surgeon alike must remember that revisions may be necessary, almost predictable, in some difficult configurations if the best possible result is desired. Revisions are frequently minor, but all patients should understand preoperatively what cannot be predicted and therefore not mistake the uncontrollable for the uncontrolled. The patient must know preoperatively that no revision should be undertaken until the end of the first postoperative year. Resolution of swelling and stabilization of the final appearance take at least that long in the primary nose and often longer in patients undergoing secondary rhinoplasty; during that time, irregularities, asymmetries, or poor contours that initially appear to require revision may improve sufficiently without surgery. Nothing should be done until healing is complete. The surgeon should control every possible variable.
Who should perform the revision? To some degree, the answer depends on the same factors involved in the prior rhinoplasty. The surgeon’s model and proposed solution should be clear, and the patient’s goals reasonable; patient and surgeon must understand each other explicitly. Each operation is geometrically more difficult than the last.
What limits the applicability of most proposed aesthetic ideals is the character, volume, and distribution of the skin sleeve and the limitations that they impose. Three soft tissue parameters can be used to form any rhinoplasty plan,76,77 and they will therefore apply to both primary and secondary patients.
It may be intuitively obvious that skin thickness affects any rhinoplasty plan, but so also does skin distribution. The preoperative large nasal base does not contract into a small nasal base; rather, it contracts to a distorted large nasal base. Skin quality therefore affects both reduction and augmentation. Thicker skin requires more skeletal support and contracts less well; the surgeon must thus be conservative in reduction and will need more substantial grafts to produce a given result (Fig. 19.10A,B). Thinner skin allows greater reduction but requires softer grafts to avoid surface distortions (Fig. 19.10C,D).
Fig. 19.10 (A,B) Patients with thick nasal skin; skeletal reduction must be more conservative and augmentations more substantial to provide a given result. (C,D) Patients with thin nasal skin. Although more soft tissue contraction can be expected, skeletal irregularities and graft visibility are more likely, and techniques must be altered accordingly.
Because the nasal base (the lower nasal third) has a more complex topography than the simpler pyramidal bony and upper cartilaginous vaults, and because the soft tissues are always thicker in the caudal than in the cephalic nose, it follows that the surgeon should select first those maneuvers that provide the best nasal base contours. Ideal tip aesthetics (Fig. 19.11A) require a defined point of greatest projection, a flat supratip, and a tip lobular mass that falls below the point of greatest projection. The poorly shaped tip lobule has the opposite characteristics: a poorly defined, low point of greatest tip projection, a convex supratip, and a tip lobular mass that lies cephalad to the point of greatest projection (Fig. 19.11B).
(B from Constantian MB. Experience with a three-point method for planning rhinoplasty. Ann Plast Surg. 1993; 30:1. D from Constantian MB. Four common anatomic variants that predispose to unfavorable rhinoplasty results: a study based on 150 consecutive secondary rhinoplasties. Plast Reconstr Surg. 2000; 105:316.)
Tip lobular contour is important for two reasons. Simple alar cartilage reduction cannot raise the level of the alar dome peaks or redistribute tip lobular mass but instead only produces a smaller replica of the same preoperative tip. To create an aesthetic lobule from a poorly shaped configuration, the surgeon must raise the level of greatest projection and increase lobular mass caudal to this point, effectively lengthening the middle crural alar cartilage segment. The tip change is one of contour, not only of volume.
Dorsal reduction or augmentation profoundly affects the apparent size of the preoperative nasal base.77 The higher the dorsum, the smaller the nasal base appears (Fig. 19.12). The reverse is also true: dorsal reduction increases apparent nasal base size. This powerful illusion has its most important practical application in: (1) patients who believe that preoperative nasal base size is excessive, in whom the aesthetic goal may best be reached by a change in balance instead of only size (Fig. 19.13A,B); and (2) patients whose soft tissues are thick, and who therefore may be more successfully treated by the combination of reduction and augmentation (Fig. 19.13C,D), a paradoxical principle that most patients and many surgeons have to see to believe.
Fig. 19.12 (A,B) The effect of bridge height on apparent nasal base size. Although both nasal bases (lower nasal thirds) are the same size, the nasal base on the right appears larger because the dorsum and nasal root are lower. This illusion provides an important diagnostic and therapeutic tool. (C–F) Low radix, in each case, corrected by augmentation. Notice the apparent difference in nasal base size and balance, caused by the alteration in dorsal configuration.
Fig. 19.13 (A,B) Patients who believe that preoperative nasal base size is excessive, in whom the aesthetic goal may best be reached by a change in balance instead of only size, and (C,D) patients whose soft tissues are thick, and who therefore may be more successfully treated by the combination of reduction and augmentation, a paradoxical principle that most patients and many surgeons have to see to believe.
Endonasal rhinoplasty is an operation designed around changes in the skin surface. The skeleton is only a means to that end. Critical indicators such as skin sleeve movement, balance changes, and the effects of reduction and augmentation all depend on an ability to see the undisturbed nasal surface accurately. This is the anatomy that the patient sees and that determines the success of the surgical result; this is the right-brain part of the operation.
Although not a new operation, open rhinoplasty has enjoyed its resurgence in the past two decades because of the frustration that many surgeons experience in performing the newer rhinoplasty techniques through the endonasal approach. Reinforcing this stimulus is the traditional respect that all surgeons have for anatomy and exposure. The advocates of open rhinoplasty properly note that binocular vision is possible, that anatomic points obscured by the skin sleeve can be uncovered, that certain techniques can be performed more easily, and that the scar itself is ordinarily imperceptible.
All of these arguments are valid. Open rhinoplasty does, however, impose its own constraints on surgeon and patient. The dissection is slower, and postoperative morbidity may be higher. Poor scars occasionally do occur. Unfortunately, although designed to do so, the open approach has not diminished the incidence or severity of secondary deformities.
These are the common objections, but not necessarily the most important ones. First, by separating columellar skin from the medial crura, the surgeon loses an important component of tip stability and projection, which therefore requires some method (suture fixation or columellar strut) to support the medial crura so that a new nasal tip can be made. The strut can impart rigidity to the columella and increases graft requirements. In primary patients, this consideration may be unimportant, but in secondary patients, whose donor sites are already depleted, every bit of graft material counts. Though incisions are limited, endonasal rhinoplasty is not a blind operation. Most procedures are performed under direct vision with greater access than endoscopic surgery permits. The operative strategy, making skeletal changes through limited incisions and judging progress by feeling the surface, is precisely the same discipline required by suction-assisted lipectomy. Limited pocket dissection minimizes the need for graft fixation and simplifies some procedures. Solid or crushed grafts can be used in ways that would be tedious or impossible by the open approach,78 although some solutions have been described.79
Rhinoplasty is made easier not necessarily by a larger incision but rather by an accurate analysis of the surgical problem and adherence to a strategy that reflects the real biologic processes at work. Almost all secondary deformities result from inaccurate recognition of anatomic variants, tissue characteristics, or functional/structural interrelationships and almost none occur because the surgeon could not see well.
3. Can I manage the patient? A patient who is unacceptably nervous, impossible to examine, or unwilling to comply with preoperative and postoperative instructions is a poor candidate, even if all other conditions are met.
4. If there is a complication, will the patient remain controlled and cooperate with treatment? No patient enjoys a complication, but there are those who, although disappointed, quietly understand and will await the proper time for revision. There are others who become hysterical, angry, disruptive, or accusatory and want an immediate correction. From the author’s experience, the personal stress of operating on the latter group and anticipating the outcome if something goes wrong is agonizing. More than that, patients whose emotions are so poorly controlled are in no position to withstand the additional trauma of surgery.
5. Does the patient accept the margin of error inherent in surgery? This is the most important criterion. Some patients (and even some surgeons) have unrealistically optimistic opinions about the degree to which any surgeon can control wound healing; the quality and availability of building materials, the patient’s immune competence, and the myriad other factors, currently known and unknown, that influence surgical outcomes. The patient’s willingness to accept the imperfection that is inherent in surgery is a willingness to accept the imperfection that is inherent in being human.
I recognized early in my career that the rhinoplasty steps that were so neatly drawn in atlases, simply did not apply in the operating room. I soon decided that there had to be a pattern to what I was seeing, but I had no idea what it was or how to recognize it; I needed time to think. I began taking sequential, intraoperative photographs after each critical step, and lateral views at the beginning and end of each of the operations, and silhouettes. Although I no longer take so many intraoperative photographs, at the very least I still photograph the nasal appearance at the beginning and end of every operation, and then at every postoperative visit. Now, after 32 years of practice, these sequences have become the foundation of my rhinoplasty understanding. After surgery, there is ample time to examine each image and decode the feedback that the nose supplies. Each surgeon needs to learn how different augmentations and reductions behave in different noses, and in his/her own hands. Surgeon needs to develop their own judgment; sequential photographs are the key.