45. Rhinoplasty

Ashkan Ghavami, Jeffrey E. Janis, Bahman Guyuron

FUNCTIONAL ROLE OF NOSE¹

■ Regulate airflow, humidification, olfaction, filtration

■ Nasal airway: 50% of airway resistance

■ Nasal cycle

• Alternating constriction and dilation of nasal mucosa on each nasal side

• Normal cycle is 4 hours.

• Abnormalities can be present from obstruction, allergies, or vasomotor irregularities (i.e., sensitivity to heat-cold changes).

RELEVANT ANATOMY

SKIN (Fig. 45-1)

Fig. 45-1 Skin and soft tissue over the radix and tip region is typically thicker and less elastic than over the dorsum.

■ Skin thickness and sebaceousness are often underestimated components in predicting final nasal shape.²

■ Skin is thickest in the lower third (tip, alae).

■ Skin is thinner in the upper and middle thirds, with more gliding.

■ Understanding the contractile properties of each patient’s nasal skin is critical to the outcome.

• Modifications of the underlying bony and cartilaginous frame (particularly at the paradomal and tip regions) may be obscured by thick, poorly contractile skin.

• Debulking of skin and soft tissue can be an important maneuver.

NASAL MUSCLES (Fig. 45-2)

Fig. 45-2 The depressor septi nasi muscle and other musculature can affect nasal shape and the tip position.

■ Nasal superficial musculoaponeurotic system (SMAS)

• Includes dilator nasi, transverse muscle fibers

• Flares nostrils

■ Levator labii superioris alaeque nasi

• Helps external valve to stay open

• Elevates nostrils

■ Depressor septi nasi muscle^3,4

• An important muscle in dynamic tip ptosis

• Raises upper lip and pulls nasal tip down

• Can be transpositioned or transected as part of rhinoplasty⁵

• Can be chemodenervated for diagnostic or treatment purposes

BLOOD SUPPLY⁵ (Fig. 45-3)

Fig. 45-3 The lateral nasal artery is one of the most important vessels in nasal blood supply, and preserving it promotes healing and helps to prevent deleterious postoperative skin changes.

■ Most blood supply is located within subcutaneous plane.

CAUTION: When debulking nasal soft tissue, do not violate the blood supply to the subdermal plexus.

■ Angular artery

• Lateral nasal branch arises from this artery 2-3 mm above alar groove.

► Supplies the subdermal plexus at nasal tip either unilaterally or bilaterally in 100% of cadaver specimens

■ External nasal valve insufficiency1,6

• Flaccid or weak LLC

• Slitlike nostril rims (vertical/narrow: iatrogenic or inherent)

• Thin alar sidewalls

• Malposition of LLC (cephalically oriented)

► Caudal edge of LLC is an excessive distance from nostril rim, so alar rim support is not provided during inspiration.

NASAL VAULTS (Fig. 45-4)

Fig. 45-4 The three nasal vaults are defined by the nasal bones (bony vault), upper lateral cartilage (midvault), and lower lateral cartilage (lower vault).

■ Three nasal vaults: Bony, upper cartilaginous, and lower cartilaginous

Bony Vault

■ Paired nasal bones and ascending process of the maxilla

■ Proximal third to half of nose

■ Ethnic variations in length may exist.

Upper Cartilaginous Vault

■ Known also as nasal midvault

■ Paired ULCs

• Underlap nasal bones 6-8 mm (keystone area)

► Widest portion of nasal dorsum

• Scroll area: Junction where ULCs underlap LLCs

• Internal nasal valve: At junction of caudal ULC and septum

• ULCs join the nasal septum at dorsum to form a T.

► Affects dorsal aesthetic lines

► Spreader grafts are placed at this junction.

Lower Cartilaginous Vault

■ Paired lower lateral, middle, and medial crura (cartilages)

■ Responsible for nasal tip shape and external valve support

NASAL TIP

■ Shape and position are critical in rhinoplasty.

■ Tripod concept: LLC and medial crura act like legs of a tripod^8,9 (Fig. 45-5).

Fig. 45-5 The nasal tip “tripod concept” helps when trying to understand dynamic changes in nasal tip shape and position defined by the central medial crura and bilateral lower lateral cartilages.

• Variations in length and strength of each structure influence tip position and shape.

■ Nasal tip supported by several ligamentous attachments^9–11 (Fig. 45-6):

• Piriform ligament: LLC abutment with piriform aperture

• Domal suspensory ligament

• Fibrous attachments between ULC and LLC

• Medial crural ligaments

• Anterior septal angle

Fig. 45-6 The suspensory ligaments affect tip projection and are weakened in an “open” approach and with aging.

SEPTUM (Fig. 45-7)

Fig. 45-7 All anatomic parts of the septum must be addressed in nasal airway obstruction, including the nasomaxillary and vomerine spicules that are often seen.

■ Septal cartilage, perpendicular plate of ethmoid, and vomer

■ Perpendicular plate of ethmoid is continuous with the cribriform plate.

• Surgical or traumatic fractures of the perpendicular plate can result in CSF rhinorrhea.

• Rhinoplasty fracture technique must be meticulous, gentle, and in a lateral direction to prevent cribriform injury.

INTERNAL NASAL VALVE (Fig. 45-8)

Fig. 45-8 The internal nasal valve is one of the most important aspects in septorhinoplasty and must be maintained open using spreader grafts and/or flaps.

■ Formed by junction of caudal ULC and nasal septum

■ Normal valve angle is 10-15 degrees.

■ Angles <10 degrees can lead to nasal airway obstruction.

■ Internal nasal valve provides 50% of total airway resistance.

■ True spreader grafts and autospreader flaps function through increasing the internal nasal valve angle.

EXTERNAL NASAL VALVE

■ Formed by caudal edge of LLC, alar soft tissue, membranous septum, and nostril sill

■ Dynamic structure

■ Nasal muscles help to keep open during inspiration

■ Alar contour grafts and lateral crural (alar) strut grafts can strengthen and reinforce external nasal valve.

TURBINATES

■ Superior, middle, and inferior turbinates

■ Extensions of lateral nasal cavity wall

■ Anterior portion of middle and lateral turbinates project into airway and can affect airway resistance.

■ Inferior turbinate is capable of up to two thirds of airway resistance at internal nasal valve region.

NASAL OBSTRUCTION1,6,12–14

TYPES OF NASAL AIRWAY OBSTRUCTION

■ Allergic rhinitis: Seasonal or obstruction related to dust, pollen, or other antigens

■ Bilateral obstruction: Possible severe mucosal disease

■ Constant-fixed obstruction: May be associated with a fixed abnormality such as septal deviation

NASAL OBSTRUCTION COMPLAINTS

■ Nasal crusting

■ Dry mouth (from mouth breathing, especially during sleep)

■ Frequent sore throats

■ Sinus problems

NASAL OBSTRUCTION HISTORY

■ Time of onset

■ Duration of obstruction

■ Precipitating events

■ Rhinorrhea (amount, duration)

■ Epistaxis

■ History of trauma or surgery

■ Use of medications, nasal sprays

■ Use of alcohol, tobacco, and drugs (especially cocaine)

■ History of headaches, visual disturbances, and middle ear symptoms

PHYSICAL EXAMINATION

■ Visual clues

• Allergic shiners: Dark circles under eyes suggesting allergic rhinitis

• Supraalar pinching or an excessively narrow midvault (inverted-V deformity) may have internal nasal valve insufficiency.

• Watch midvault motion during nasal respiration.

► If dynamic collapse occurs, midvault support will be needed.

■ Cottle test

• Treatment: Irrigation with saline solution, high-dose vitamin A, possible surgical closure of the nostrils

• As with any aesthetic procedure, expectations must be realistic and achievable (see Chapter 1).

• This becomes more of a challenge in secondary rhinoplasty patients (see Chapter 46).

• SIMON: Acronym to describe male rhinoplasty patients

► Single, immature, male, obsessive, and narcissistic

► Used as a rough guide to remind surgeon of “problem rhinoplasty patients”

• Good communication must assimilate surgeon’s analysis and goals with those of patients.

► If surgeon’s and patient’s goals are vastly different, proceeding with rhinoplasty may be imprudent.

► Asking patients to list the top three things they want to have altered may be a good general idea (particularly for patients with nonspecific aesthetic goals and those unsure of their aesthetic goals).

• Generally, rhinoplasty should address the imbalances between the nose and face.^12,15–17

► Specific desires and complaints should be addressed while pointing out other related deficiencies (when indicated), such as a deficient chin.

► For example, a patient may have a wide nasal tip but only wants “the hump gone.”

♦ Dynamic relationships must be discussed with patients.

♦ For example, significant hump reduction without elevation of a droopy tip will produce an imbalanced nose that appears flat and excessively droopy.

FUNCTIONAL

■ This chapter does not focus on functional techniques; however, when performing a rhinoplasty, comprehensively addressing the nasal airway is critical.

■ Patients without nasal airway obstruction before rhinoplasty may develop airway problems postoperatively unless preventative measures are taken.

• For example:

► Spreader grafts and flaps can help to reduce internal nasal valve narrowing when dorsal reduction and osteotomies are performed.^12,21

► External valve dysfunction can be prevented by placing lateral crural strut and/or alar contour grafts and recognizing alar malposition.

■ Septoplasty1,6,13,14,22

• Important to perform simultaneously

• Best source of most grafts used in aesthetic rhinoplasty

• L-strut must be left intact with at least 1 cm (preferably up to 2 cm) dorsal and 1 cm caudal (Fig. 45-9).

Fig. 45-9 L-strut.

• All bony protrusions and spicules should be excised to open airway effectively.

► Most critical location is across from inferior turbinate.

► A protuberant nasomaxillary crest is common and should be thoroughly addressed.

PREOPERATIVE EVALUATION^12,16,23,24

■ Preoperative analysis requires an external examination of AP, lateral, and basilar views in addition to an internal airway examination.

■ Ethnic variations should be taken into account, because anatomic variations in nasofacial morphology, as well as culture-specific goals, may not always be clear (see Chapter 47).

• Racial incongruity should be prevented.

► A nose that is off balance with the rest of the ethnic facial traits

► Skin thickness and degree of sebaceousness are best seen in AP view.

ANTEROPOSTERIOR VIEW

Symmetry and Nasal Deviation (Fig. 45-10)

Fig. 45-10 A, Dividing the face into vertical fifths can help to guide overall nasal proportion in facial width. B, A vertical line drawn down the dorsum tip, Cupid’s bow, and chin can help to determine nasal deviation, caudal deviation, and chin asymmetry.

■ AP view of face can be divided into fifths to help evaluate proportion (Fig. 45-10, A).

• Intercanthal width and alar base widths should coincide with measurements of fifths.

■ A line can be drawn to bisect the nasal dorsum, upper lip, Cupid’s bow, and central incisors to assess magnitude of nasal deviation (Fig. 45-10, B).

■ Facial asymmetries are considered.

■ Nasal deviation may be caudally located presenting a “twisted” appearance.

■ Role of asymmetry in size and shape of nasal and malar bones is evaluated.

Aesthetic Lines and Measurements (Fig. 45-11)

Fig. 45-11 A, Dorsal aesthetic contour lines are curvilinear in females and descend from the medial brow toward the tip-defining points. B, Nasal bones are generally narrower than the alar base width by about 20%-25%. C, Alar base width is generally equivalent to the medial canthi; however, many variations exist. D, Generally, aesthetically pleasing nasal tip highlights are diamond shaped.

■ Dorsal aesthetic lines (Fig. 45-11, A)

• Symmetry, deviation, width, and shape are important.

• Should be gently diverging curvilinear lines extending from medial eyebrow (superciliary ridge) toward nasal tip-defining points

■ Width of bony base (Fig. 45-11, B)

• Should be 75%-80% of alar base width

• Asymmetries may exist from different angles of inclination of the nasal bones and ascending process of the maxilla.

• Commonly, one side is wider (projecting more laterally) than the other.

■ Width of alar base (Fig. 45-11, C)

• Should coincide with intercanthal width (generally)

• If wider than intercanthal width, then degree of alar flare will dictate operative plan

• Evaluation:

■ Alar rims25–27

• Retraction or excess inherent “nostril show” is evaluated.

• On lateral view, alar-columellar relationship should be balanced.

• Should have a natural flare and inclination

• Outline of infratip breakpoint should appear like a “seagull in gentle flight.”

■ Nasal tip (Fig. 45-11, D)

• Four tip-defining points: One on each dome apex, a supratip break, and a columellar-lobule breakpoint

• Lines can be drawn to assess asymmetry.

• Domal angle and angle of domal divergence are assessed.

• Imbalance in nasal tip aesthetic contour has various descriptions, such as bulbous, boxy, amorphous, and wide.

■ Lobule

• Excess columella or hanging columella leads to excess infratip lobule.

• Breakpoints should be in harmony making a diamond shape.

► Caveat: Ethnic and gender variations should be considered.

BASILAR VIEW^26,28,29 (Fig. 45-12)

Fig. 45-12 Nostril height is approximately 60%, whereas infratip height is 40%, of the basilar view height. Ethnic variations exist particularly relative to nostril length and shape.

■ Alar rims should form an equilateral triangle.

■ Nostril height (columellar length) to infratip lobule height ratio should be approximately 60:40, respectively.

■ Nostril inclination is approximately 60 degrees.

■ Nostril has teardrop shape.

■ Alar rims should not be excessively concave or convex, within the confines of an equilateral triangle.

■ Multiple lengths and angles contribute to an aesthetically pleasing lateral view (Fig. 45-13).

Fig. 45-13 Numerous breakpoints and angles help to define a pleasing lateral nasal view.

■ Nasofrontal angle (NFA)

• Located at upper lash line and supratarsal crease (Fig. 45-14)

Fig. 45-14 The nasofrontal angle and position affect the appearance of the nasal length and femininity versus masculinity. (D, Dorsum; G, glabella; N, nasion.)

• Formed by the intersection of the line between the glabella and the soft tissue nasion and the nasal dorsum tangent

• NFA should be approximately 140 degrees.

■ Dorsal curvature

• Determined by a line drawn from the radix at the NFA to the tip-defining point (Fig. 45-15)

Fig. 45-15 The radix is often higher and the nasofrontal angle more obtuse in men versus women. (TDP, Tip-defining point.)

• Female dorsum should be 2 mm posterior to this line.

• Male dorsum should be at or slightly anterior to this line.

• Angle of this line and where it begins can change the appearance of length.

► Radix can be high or low.

► Deep and inferiorly located radix has shortened nasal length (Fig. 45-16).

Fig. 45-16 Tip projection, dorsal curvature, and radix depth affect nasofacial balance, and variations are important to recognize in patient preference.

■ Tip projection (Fig. 45-17)¹⁶

Fig. 45-17 Tip projection. A, The nasal tip is generally 50% of the total nasal projection from the alar-cheek junction. B, The nasal projection is approximately 67% of the nasal length (radix or nasal root to the most projected tip point). Morphological variations and preferences exist.

• Ideally tip projection should be 50%-60% of the distance of a line drawn from the alar-cheek crease to the most anterior tip point (see Fig. 45-17, A).

• Alternatively, tip projection is 0.67 × the nasal length.⁵

• Can also be assessed on basilar view

• Must be proportionate to chin and lip projection

■ Tip rotation (Fig. 45-18)

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