Indications and Technique for Closed Rhinoplasty in Patients With Dorsal Hump and Wide Tip

Barış Çakır

Ali Teoman Tellioglu

ANATOMY

The nose consists of mobile and immobile areas.
The mobile part of the tip consists of the lower lateral cartilages.
The immobile part of the nose consists of the septum, the upper lateral cartilages, the maxilla, and the nasal bones (FIG 1).
The mobile nose tip is connected to the septum and the upper lateral cartilages by means of the Pitanguy and scroll ligaments. The nose tip moves up and down along these ligaments.
The scroll and Pitanguy ligaments are formed by a thickening of the superficial musculoaponeurotic system (SMAS) at the supratip; they are functionally significant because they constitute a part of the SMAS.
Protection and repair of these ligaments are crucial for the projection, mobility and definition of the nose.

FIG 1 • The nose consists of mobile and immobile areas. The mobile part of the tip consists of the lower lateral cartilage. The immobile part of the nose consists of the septum, the upper lateral cartilages, the maxilla, and the nasal bones.

PATHOGENESIS

The cartilages and bones that form the skeleton of the nose stand in close relation to each other.
Many patients present with a history of trauma to the nose. Generally, one can observe a large and deviated vomer.
Our theory is that a greatly enlarged septum pushes the upper lateral cartilages anteriorly and the medial crura caudally.
The upper lateral cartilages pull the cephalic edge of the lateral crus anteriorly and therefore distort the resting angle of the lateral crura.
A septal cartilage that projects anterocaudally results in the domes being formed more caudal than normal.
The lobule is formed short, while the lateral crura are long. The nasal tip widens because the lateral crura become more dominant in the tip area.
The convex nature of the lateral crura and the distorted reclining angle of the lateral crura result in the tip appearing wide and round (FIG 2).

PATIENT HISTORY AND PHYSICAL FINDINGS

Noses that are not in harmony with the face and have flawed internal proportions may disturb patients from an aesthetic viewpoint.
Patients generally complain that their nasal tip is big and that they find the bridge disturbing.
Inspection: A visual examination is most important; problems are clearly diagnosed with the help of photographs.
- The nasal tip is wide.
- The lobule is generally short.
- The lateral crura are generally convex, long and wide.
- The cephalic edge of the lateral crus is more anteriorly located than the caudal edge.
- The dorsal septum and the nasal bones are hypertrophic.
- Because the septum pushes the tip forward, the more than normally projecting nasal tip is likely to be pulled downward when the patient laughs.
Palpation
- Skin thickness directly influences the results. Strong cartilages and thin skin respond better to rhinoplasty surgery. By touching the nasal skin and examining the inside of the nasal tip with the help of a light source, we can gain valuable information about the soft tissue and cartilages.

IMAGING

Front, base, top, lateral, and oblique photographs are standard procedure. A lateral photograph of the patient smiling gives clues about the dynamics of the nasal tip.

FIG 2 • A-H. The lobule is formed short, the lateral crura long. Because the lateral crura become more dominant in the tip area, the nasal tip widens. The lateral crura’s convex nature and the distorted reclining angle of the lateral crura result in the tip appearing wide and round.

An SLR camera of medium quality is sufficient. One can obtain a detailed and standard photographic archive with a 100- or 105-mm fixed macro lens.
On close-up photographs, the nasal tip appears wider. In order to objectively depict the changes in the nasal tip, the camera’s focal length has to remain the same.
A black or blue background is preferable. A black background prevents a black shadow and looks better but may render the hair invisible. Blue is a color more appropriate for scientific purposes.
Lighting changes the photographic results. The double softbox system is standard. To obtain standardized photographs, patient, the doctor and the lighting need to remain in the same location. It is advisable to draw a circle on the floor about 1 to 2 m in front of the background curtain.
Lighting: To understand the lighting technique, one has to look at the eyes first. If the light reflection is not the same between the preoperative and postoperative photographs, it is difficult to make a comparison.
Fish-eye effect: If the before photograph is taken with a fisheye effect, the ears will not be visible. It is not possible to draw a meaningful comparison between two photographs with unequal focal distances.

SURGICAL MANAGEMENT

Rhinoplasty surgery began in the form of closed reduction; however, a more controlled resection and reconstruction with an open rhinoplasty technique have become more popular.
Closed surgery based on an intracartilaginous approach, where the surgeons could not see the tip cartilages, has quickly lost popularity. Because control is difficult to achieve, more inexperienced surgeons do not prefer this technique because it is difficult to achieve control.
Because it is easy to learn and perform open rhinoplasty, this technique has gained great popularity in recent years.
Although open rhinoplasty allows for more control, side effects such as rigidity and numbness are quite bothersome.
In an effort to combine the control of open rhinoplasty techniques with the fast healing of the closed rhinoplasty, “open rhinoplasty with endonasal approach” has become an alternative approach. We named this philosophy as the “preservation rhinoplasty.”

Preoperative Planning

It is important to do the imaging work on a lateral photograph before the surgery.
By doing the imaging work together with the patient, we can learn about the patient’s expectations.

Approach