The ultimate goal of any rhinoplasty is to have a pleasing nose that is harmonious with the rest of the face. Thus, a circumspect assessment of the entire face and analysis of the life-size photographs ¹ is crucial because imperfections of other parts of the face that have been missed can detract tremendously from a nose that would otherwise have an ideal configuration. It is the congruity of the nose with other facial structures that, regardless of the magnitude of the change in the nose, avoids the appearance of ‘surgical nose’. The other cardinal rule in achieving a desirable rhinoplasty outcome is to create an optimal balance between different segments of the nose itself. Each rhinoplasty step has to be logical and purposeful and must incorporate a full understanding of the dynamic changes that will ensue.

Operative Technique

The life-size photographs that have been analyzed using the soft tissue cephalometric principles described in Chapter 2 are hung from an IV pole next to the patient to be referred to during the surgery.¹ The procedure is performed almost exclusively under general anesthesia in the author’s practice, unless a minor revision is planned. The nasal hair is trimmed using a pair of curved iris scissors and a piece of 0.5 inch (13 mm) adhesive tape wrapped around the end of a Q-tip is used to remove any hair particles (Video 4.1). The internal nose is cleansed and the face is prepped with Betadine solution and washed with saline solution.

Video 4.1 •

Vasoconstriction

If a turbinectomy is part of the surgical plan, the turbinates are injected with xylocaine containing 1 : 200 000 epinephrine using a 35 gauge spinal needle (Video 4.2a). The nose is packed with gauze saturated in oxymetazoline hydrochloride or phenylephrine solution, the gauze being placed as far cephalically and posteriorly as possible to cause vasoconstriction in the areas that are hard to reach through injection (Video 4.2b). The nose injection is started from the radix (Video 4.2c). The soft tissues along the lateral and medial surface of the nasal bones are injected profusely. The base of the nose and the columella are injected next. The dorsal portion of the septum is injected on either side of the nasal roof as completely as possible. The lining on either side of the vomer bone is also injected along the floor of the nose as far posteriorly and caudally as possible to reduce bleeding during the septoplasty. After allowing a few minutes for the effect of the epinephrine, the injection is resumed, this time using 0.5% ropivacaine containing 1 : 100 000 epinephrine (Video 4.3). This double injection will minimize the potential for a systemic reaction and provide several hours of anesthesia. Otherwise, injection of the solution containing 1 : 100 000 epinephrine as the initial step can often induce hypertension, tachycardia, and even arrhythmia. Inclusion of ropivacaine and epinephrine minimizes discomfort during the immediate postoperative period, reducing the need for analgesics.

Video 4.2a • 4.2b • 4.2c • 4.3

Incision

The incision is marked in the narrowest portion of the columella while the domes are pulled anteriorly using a blunt double hook. Before the incision is made, the skin hook is released to ensure that the incision is not too close to the nostrils. After allowing time for vasoconstriction, a step incision is made in the mid-columella and is continued along the caudal margin of the medial and lateral crura of the lower lateral cartilages (LLC) (Figure 4.1; Animation 4.1; Video 4.4). This incision provides the least visible scar and the best alignment of the wound margin at the time of repair.

Figure 4.1 Illustration of the design of the step columellar incision.

Animation 4.1 •

Video 4.4 •

Next, a single skin hook is placed under the right nostril to evert the alar margin while the operator’s non-dominant index finger everts the ala, exposing the caudal margin of the lateral crus of the LLC. This incision is made on the left side in a similar fashion (Video 4.5). Using a pair of baby Metzenbaum scissors and a spread-and-cut technique, the soft tissues overlying the medial crura and the domes are separated from the underlying frame (Video 4.6). The dissection is continued cephalically to expose the anteromedial two-thirds of the lateral crura. In patients with thin skin, as much soft tissue as possible is raised with the skin flap side (Video 4.7). In patients with thick skin it is preferable to raise a healthy skin flap and maintain a robust circulation to it, leaving some of the fibrofatty tissue attached to the lower lateral cartilages, and mostly between the domes, to be subsequently dissected and discarded. The dissection is continued along the dorsum using the Metzenbaum scissors until the nasal bones are reached. At this point, an Obwegeser periosteal elevator is used to elevate the periosteum from the dorsum, making every effort to maintain the dissection in the subperiosteal plane (Video 4.8). Preservation of the periosteum will protect the overlying muscles, provide a more natural shape to the nose, and make any minor residual nasal imperfections less discernible. Violation of the periosteum and thinning of the soft tissues may result in visibility of the minor dorsal flaws, potential dimpling of the nose skin on animation, and telangiectases, common displeasing sequelae seen in patients who have undergone multiple previous rhinoplasties.

Video 4.5 • 4.6 • 4.7 • 4.8

The dorsum is now packed with gauze saturated with 1 : 50 000 epinephrine. A few minutes are allowed for the effect of the epinephrine to take place and the packing is removed.

Assessment of the Bleeding

At this point, nose bleeding is carefully evaluated. If it is deemed excessive, the blood pressure is measured by the anesthesiologist. If the systolic pressure is higher than 120 mmHg, it is reduced to this level by the anesthesiologist. In the absence of hypertension, excessive bleeding is commonly the consequence of either von Willebrand’s disease or consumption of aspirin or nonsteroidal anti-inflammatory drugs, either of which will often respond favorably to the infusion of 0.3 µg/kg of body weight of DDAVP (desmopressin) dissolved in 50 ml injectable saline and infused over 30–45 minutes.¹⁰

Deepening the Radix

If the radix needs to be deepened after the periosteum is sufficiently elevated, a guarded burr will be used to achieve this (Figure 4.2; Video 4.9).² While the burr is running, it is gently moved from side to side, not cephalocaudal, in order to avoid penetration of the frontal sinuses. The mid-portion of the burr is lined up with the upper tarsal crease. This is a very powerful tool and can produce sufficient deepening without too much effort. Additionally, the burr can generate significant heat, which can damage the soft tissues. It is therefore extremely important to lower the radix incrementally.

Figure 4.2 Artistic rendering demonstrating the use of a guarded burr is used to deepen the radix.

Video 4.9 •

Removal of the Dorsal Hump

After the radix is deepened, the dorsal hump is eliminated. On patients with a large hump, it is often necessary to first remove a portion of the hump. Otherwise, one may face resistance in advancing the guarded burr in the desired site. In an ideal nasal frame, the nasion is deeper than the rest of the dorsum to accommodate the thicker soft tissues overlying this zone of the nose. The carbide push and pull rasp (Black & Black, Inc.) is then used to remove the bony hump. The rasp is activated in an oblique rather than a cephalocaudal direction, to minimize the potential for an inadvertent fracture of the septum. This is further minimized by placing the left index finger and thumb on either side of the nasal bones in such a way that, if the rasp slips, the digits will prevent it from damaging the septal frame (Figure 4.3; Animation 4.2; Video 4.10a). The rasping is done incrementally until the bony dorsum appears optimal and an adequate step is created between the bony and the remaining cartilaginous dorsum, indicating the magnitude of reduction in the dorsal hump (Video 4.10b). The cartilaginous dorsum is left alone at this point.

Figure 4.3 Artistic rendering of removal of the dorsal hump.

Animation 4.2 •

Video 4.10a • 4.10b

Removal of the Cephalic Margin of the Lower Lateral Cartilages

The Lateral Crus Stabilizer Black & Black Surgical, Inc. is then used to harness the LLC. Maintaining about 4–5 mm width of LLC anteriorly and 6 mm or more posteriorly, the excess portion of the cartilage is removed (Figure 4.4; Animation 4.3; Video 4.11).³ The incision in the cartilage is made with a no. 15 blade, and a pair of iris scissors is used to dissect and remove the excess cartilage. The mucoperichondrium is maintained intact, if possible. If the removed cartilage is thick and rigid enough it can be used as the alar rim graft. It is important to leave a symmetric amount of LLC in place since most of the time the LLCs are not symmetrical and, if one is focused on removing an equal amount of the LLCs, the remaining cartilages may not be symmetrical.