Controlling the shape of the nasal bones has long been a frustrating problem. Conventional osteotomies are associated with bleeding, loss of reduction, inability to achieve the desired alignment, improperly placed osteotomy sites, and spicule formation. A nonpowered osteotomy method empirically provided the safest and most controlled technique to achieve the desired anatomic result. The nasal bones should be thought of as 2 thin nasal plates that can be released from their medial and lateral attachments to become mobile units that can affect the dorsal width and bony base independently. There is a learning curve to osteotomies.
Key points
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Nasal bone issues can be classified into broad dorsum, broad base, and both broad dorsum and base.
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There is a zone of dense bone that should be avoided when doing osteotomies to minimize bleeding and spicule formation. Proper vasoconstriction minimizes bleeding after osteotomy.
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A low-to-low osteotomy results in mobilization of the base. The bone tends to migrate medially, but can be manipulated into a more lateral position.
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There is a learning curve to the use of the low-to-low osteotomy. One has to know where the guard of the osteotome is located at all times.
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Osteotomy results are independent. Dorsal changes can be made independently and separately from base changes.
Introduction
Nasal bone osteotomies have a complicated history. The problems plastic surgeons have been struggling with include (a) an inability to achieve the proper shape (eg, sufficient reduction in width), (b) an inability to maintain that shape over time (recurrence of deformity), (c) avoiding excessive bleeding during and after surgery, (d) improper location of osteotomy sites with resultant step-off deformities, (e) spicule formation, and (f) collapse of the nasal bones.
There has been a great deal of controversy regarding choice of osteotomy sites, for example, medial oblique, low-to-high lateral osteotomy, high-to-low lateral osteotomy, and medial osteotomy that is perpendicular to the long axis of the bone. It has been recognized that an osteotomy that is too wide, for example, wider than 3 mm, can damage the periosteum, causing excessive bleeding. It is also known that there is a region of dense bone that one should avoid to minimize bleeding and spicule formation—a zone 30° off the midline where the bone is excessively thick. The actual nasal bones are relatively thin plates.
Various access sites for osteotomies have been used including percutaneous, intranasal, and the buccal sulcus. Bleeding has been a formidable problem but mitigated in large part by smaller osteotomies. This requires a certain manual skill that comes from some practice—a significant but not insurmountable learning curve. Without acquiring that skill, the surgeon can have great difficulty executing the cut in the proper location (eg, low-to-low) and can have great difficulty even making the cut completely in the patient with very dense bones. Although possible, the potential for damage to the medial canthal region or structures cephalad to the nasion (intracranial) is remote. The issue is more one of getting the actual bone cut in the lowest (most posterior) location as possible to avoid a step-off and to truly narrow the entire nasal bone width. The medial oblique osteotomy does not require as much of a learning curve.
Today, there is a movement underway to use power tools because these tools can make the actual bone separation an easier process. Physical restraint of the hand is not required, as is the case when using osteotomes. The principal disadvantage of the osteotome is that the surgeon must maintain a high degree of tension on the tool with his or her hand to prevent it from suddenly slipping forward out of control when struck by the mallet. There is also the assertion that there is less bleeding associated with power tools. The main disadvantage of power tools, of course, is cost, and in some situations, the need to do a wider dissection to get exposure for introduction of the larger power tool.
For those who do not have power tools, we offer a technique that in our hands has resulted in minimal bleeding and, most important, full control of the bones in a highly reproducible fashion.
Introduction
Nasal bone osteotomies have a complicated history. The problems plastic surgeons have been struggling with include (a) an inability to achieve the proper shape (eg, sufficient reduction in width), (b) an inability to maintain that shape over time (recurrence of deformity), (c) avoiding excessive bleeding during and after surgery, (d) improper location of osteotomy sites with resultant step-off deformities, (e) spicule formation, and (f) collapse of the nasal bones.
There has been a great deal of controversy regarding choice of osteotomy sites, for example, medial oblique, low-to-high lateral osteotomy, high-to-low lateral osteotomy, and medial osteotomy that is perpendicular to the long axis of the bone. It has been recognized that an osteotomy that is too wide, for example, wider than 3 mm, can damage the periosteum, causing excessive bleeding. It is also known that there is a region of dense bone that one should avoid to minimize bleeding and spicule formation—a zone 30° off the midline where the bone is excessively thick. The actual nasal bones are relatively thin plates.
Various access sites for osteotomies have been used including percutaneous, intranasal, and the buccal sulcus. Bleeding has been a formidable problem but mitigated in large part by smaller osteotomies. This requires a certain manual skill that comes from some practice—a significant but not insurmountable learning curve. Without acquiring that skill, the surgeon can have great difficulty executing the cut in the proper location (eg, low-to-low) and can have great difficulty even making the cut completely in the patient with very dense bones. Although possible, the potential for damage to the medial canthal region or structures cephalad to the nasion (intracranial) is remote. The issue is more one of getting the actual bone cut in the lowest (most posterior) location as possible to avoid a step-off and to truly narrow the entire nasal bone width. The medial oblique osteotomy does not require as much of a learning curve.
Today, there is a movement underway to use power tools because these tools can make the actual bone separation an easier process. Physical restraint of the hand is not required, as is the case when using osteotomes. The principal disadvantage of the osteotome is that the surgeon must maintain a high degree of tension on the tool with his or her hand to prevent it from suddenly slipping forward out of control when struck by the mallet. There is also the assertion that there is less bleeding associated with power tools. The main disadvantage of power tools, of course, is cost, and in some situations, the need to do a wider dissection to get exposure for introduction of the larger power tool.
For those who do not have power tools, we offer a technique that in our hands has resulted in minimal bleeding and, most important, full control of the bones in a highly reproducible fashion.
Classification of nasal bone deformities and pertinent anatomy
Nasal bone issues can be classified into (a) type I, broad base, (b) type 2, broad base and dorsum, and (c) type 3, broad dorsum only. In Fig. 1 A, the patient has a broad base. Clearly, any method to reduce the base is going to solve the problem. Unlike the low-to-high approach, the low-to-low approach goes more cephalically and has the potential to reduce the more cephalic (upper) part of the nasal bone. In Fig. 1 B, the patient has a broad dorsum and broad base. In Fig. 1 C, the dorsum is broad (as is the middle one-third of the nose), but the base is not. This is not uncommonly seen after a lateral osteotomy that reduces the base but typically fails to reduce the dorsum. The result is that the nasal bone plates are parallel to one another, which gives the nasal bone region a “hot dog” shape. The purpose of classifying bones in this fashion is to appreciate what is and what is not required surgically to correct each deformity. Thus, the broad dorsum patient does not need a base reduction, for example, and therefore does not need a lateral osteotomy.
The triangular area in the medial aspect near the nasion is the zone of dense bone that should be avoided when doing osteotomies to minimize bleeding and spicule formation ( Fig. 2 ). The bone in this region can be 3 to 6 mm in thickness, and it is rich with blood vessels. The typical “medial osteotomy” runs parallel to the septum and runs into this dense bone and its blood vessels. When outfractured, an unwanted spicule of bone typically results. This spicule is extremely difficult to set back into position to give a smooth surface. It is best to simply avoid this region of the bony anatomy. Exclusive of this dense zone, the nasal bones are simply thin plates attached medially to the dorsum, laterally to the maxilla, and cephalically to the area adjacent to the nasion.
The surgical concept that is key to success is to conceptualize the nasal bones as plates that need to be released from their medial and lateral attachments to be manipulated into any desired position. By leaving a small cephalic bony attachment or an intact periosteum deep to the nasal bone plate, the plates will have a greenstick quality and will not collapse.
Vasoconstriction
Proper vasoconstriction minimizes bleeding after osteotomy. This includes direct injection of epinephrine deep to the nasal bones. For general anesthesia cases, a mixture of xylocaine (Lidocaine) and bupivacaine (Marcaine) with fresh epinephrine is used. Twenty milliliters of xylocaine and 15 mL of bupivacaine are mixed with 0.5 mL of 1:1000 epinephrine to make a solution that has a 1:70,000 concentration of epinephrine. This is a concentrated solution and therefore must be injected incrementally for the entire nose at the beginning of the case. Later during the surgery, the inside of the nasal bones are infiltrated with the solution at least 7 minutes before the osteotomy. The injection is performed along the inside of the nose where the turbinates are located. In essence, the local anesthetic solution fills some of the turbinates and migrates up along the medial wall of the bone.
One of the most important recent additions to our protocol is the use of desmopressin as a routine part of rhinoplasty ( Fig. 3 ). Guyuron and colleagues have pioneered use of this drug for maxillofacial surgery and for epistaxis treatment. Gruber and associates have used it routinely for rhinoplasty to minimize postoperative ecchymosis and edema. The recommended dose is 0.3 μg/kg, and it is given at least 20 minutes before the desired effect. There are very few reported complications and no reported cases of thrombosis we are aware of at this time. We use it routinely for all rhinoplasty cases if the field is not hemostatic to our satisfaction for whatever the reason. We use a smaller dose, however (0.1 μg/kg and increase it 20 minutes later if needed, and again 20 minutes after that if needed). We use the full dose for most patients who require osteotomy because they are likely to experience a good deal of ecchymosis.
