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In this Chapter Online at experconsult.com

Correction of the Typical Features of Cocaine Nose Animation 15.1

Corrective Surgery on Another Patient with Significant Nasal Deformity Related to Cocaine Use Animation 15.2

Pearls

In 1912, Owens first reported on the effects of cocaine on the nasal mucosa.¹ Recreational use of cocaine has been rising in the USA and the nose is the most common route for ingestion.² The intense vasoconstriction of the nasal mucosa resulting from insufflation of cocaine causes an array of caustic effects with varying degrees of damage to the nasal lining.³ The additive nature of the insult may ultimately result in complete necrosis of all layers of the septum and nasal wall. As the necrosis deepens, an infection may superimpose and cause additional loss of soft tissues and cartilage. With further use of cocaine, the perforation expands and often results in collapse of the dorsum, retraction of the ala, and foreshortening of the nose.⁴

Some propose the use of microvascular techniques for repair of the perforated septum.^5,6 However, in the author’s view, this type of heroic measure, which may in fact constrict the airway due to the bulk of the flap, may not be necessary in most patients.

Patient Assessment

Prudent care of the patient with this deformity begins with an in-depth evaluation of the patient’s frame of mind. The number one criterion for successful correction of a cocaine nose deformity is evidence of the patient’s commitment to abandon cocaine use, which should be confirmed by an independent qualified specialist. Otherwise, the gratifying result that is attained can easily be destroyed by insufflation of additional cocaine. This lifestyle change should have lasted for at least 3 years before surgery is considered.

The magnitude of the nose deformity should not distract the examiner and result in focusing on the nose only. It is still crucial to pay attention to the entire face rather than concentrating only on the nose. The surrounding structures and even the distant facial features should be assessed, as in primary and secondary rhinoplasty patients, prior to focusing on the nose. One important adjacent structure to examine is the maxilla.

The magnitude of the nasal deformity varies from patient to patient. There could be a small perforation in the septum with no reflection on the external appearance of the nose. However, those who seek the assistance of a plastic surgeon often demonstrate extensive nasal deformity. The common features of cocaine nose include foreshortening, an inverted V deformity and deviation at various levels of the nose structures. The deviation is largely related to the substantial destruction and necrosis within the insufflation tract. For a right-handed person, this is usually the right side of the nose. Because of the loss of alar support, the nasal tip is pulled to the affected side. Collapse of the dorsum results in a saddle-nose deformity and foreshortening with over-rotation of the tip. Loss of the septum may result in retraction of the columella. In this scenario, the entire nose will become shorter, rather than the tip simply rotating cephalically. The dorsal collapse also results in a hump that was not there previously. This is often the consequence of a posterior shift of the dorsal soft tissues while the bony frame remains intact and protrudes anteriorly in relation to the rest of the dorsum. Additionally, the collapse of the dorsum results in a lateral distribution of the soft tissues and widening of the nose and the alar base. Nasal tip projection is commonly reduced because of the loss of the support ordinarily provided by the anterocaudal septum. The nose appears significantly distorted on the basilar view. The columella deviates to the affected side, which results in a misaligned tip structure. The ala becomes notched and concave on the affected side and often the alar base is malpositioned.

Related posts:

Elongation of the Short Nose Correction of Alar Rim Deformities Correction of the Overprojected Nose Achieving Optimal Tip Projection Secondary Rhinoplasty Patient Assessment for Rhinoplasty

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