CHAPTER 39 Secondary rhinoplasty

History

The spectrum of patient problems that are encountered in secondary rhinoplasty are so broad and varied, that creating a “cookie-cutter” format for performing them is close to impossible. To truly understand the complexity that is secondary rhinoplasty, it is important to have a basic grasp of the spectrum of procedures used in primary rhinoplasty. Therefore, review of the myriad of techniques employed in primary rhinoplasty both currently and in the past is prudent prior to reading further in this chapter.

Although a thorough targeted history focusing on previous operations, trauma, and substance abuse is helpful, the first question that you must ask any potential secondary rhinoplasty patient is: “What is the problem with your nose?” Doing so frequently helps to clarify and stratify the problems. Most patient complaints are either functional (“I can’t breath,” “My tip plunges when I smile”); or cosmetic (“It looks too done,” “The tip has no definition,” “My nostrils are too big,” “My columella hangs down”). As the surgeon, your first obligation for the secondary patient is to determine if the patient’s exam is consistent with their concerns. Any significant discordance could likely be the major indicator for an underlying personality disorder. Psychopathology aside, many patient personalities will not be a good match for your practice style. It is helpful to ask yourself, “Would I have operated on this patient for his/her primary operation?” Then, if the subjective complaints match up with the objective exam, the next pertinent issue is whether or not you will be able to correct the problem(s) that exist.

Patient evaluation

• Determine the patient’s top three concerns (airway and aesthetic).

• Obtain thorough, but targeted history.

• External exam: Assess skin envelope, asymmetries, support of all three vaults and shape of the radix, dorsum, sidewalls, tip, base and alar regions.

• Internal exam: Assess septum, internal valve, bone spurs and turbinates.

• Septal support: Use a Q-tip to push on septum; apply Afrin spray to rule out perforations and synechiae.

• Include an ear, scalp and chest wall exam for potential graft material.

• Photographs and analysis.

Anatomy

The “normal” anatomical structures have frequently been drastically altered during the primary rhinoplasty procedure, so the textbook perspective of nasal anatomy usually does not apply. What is seen instead is a wide range of extremes: very thick or very thin skin, under-resected and over-resected dorsums, under-rotated and over-rotated tips, etc. Because this vast spectrum of problems exists, a true understanding of the aesthetically ideal relationships is essential so that the secondary surgeon can rebuild the nose; sometimes from scratch. This allows the surgeon to establish: (1) The patient’s native anatomy; (2) Iatrogenically missing structures; and (3) Components that need restoration to help rebuild the desired form and function.

The radix

The nasion refers to the deepest point of the nasofrontal angle (ideally 134 degrees) and typically lies 4–5 mm cephalad to a horizontal plane drawn through the lateral canthus. This usually corresponds to a point between the lash line and the upper eyelid crease. The ideal nasion point lies about 4–6 mm posterior to the vertical glabellar tangent and about 10–11 mm anterior to the vertical corneal tangent. Establishing the correct nasion point is critical, since it will determine the nasal start point and subsequently help to establish nasal length. The radix is not a point, but instead is an area centered at the nasion that extends from the intercanthal plane to the nasion point and then for a comparable distance cephalad. The most cephalad aspect of the radix roughly corresponds to the level of the naso-frontal suture line.

The dorsum

The three most important factors relating to the dorsum are height, straightness and integration. The osseocartilaginous vault that comprises the dorsum is formed embryologically by cephalic ossification of the cartilaginous nasal placode. This explains the great overlap of the nasal bones over the upper lateral cartilages, which measures 11 mm in the midline and 4 mm out laterally. Thus the bone and cartilage do not simply join together in a seam, but rather overlap in a bayonet-type configuration. The inclination of the lateral walls from the maxilla is roughly 57 degrees. The cartilaginous vault is a single anatomical entity; not a septum with two juxtaposed upper lateral cartilages. The overlying soft tissue envelope is thickest at the radix area, where the procerus muscle rises from the bony vault to insert into the forehead. The envelope is thinnest over the rhinion. On anterior view, the parallel dorsal lines are a continuation of the supraorbital ridge lines which narrow at the radix and then run down to the tip defining points. The ideal width of the lines frequently corresponds to the width of the tip defining points and is 6–8 mm in females; 8–10 mm in males. The base bony width is the widest point of the nose at the level of the maxilla. The ideal final aesthetic line is concave for females and straight for males.

The usual concerns in the tip are volume, definition, width, rotation and projection. In secondary cases, distortion, deformity and deficiency must also be considered. The tip is composed of the paired lower lateral (alar) cartilages, each of which is composed of three crura; medial, middle and lateral (Fig. 39.1). The medial crus is comprised of the lower footplate segment and the superior columellar segment. The columellar–lobular junction marks the transition from the nasal base to the tip lobule and usually corresponds to the nostril apex (1–2 mm). The middle crus extends from the columellar–lobular junction to the lateral crus. The middle crus consists of the medial lobular segment and the more lateral domal segment. It is the domal segment that normally contains both the medial genu (the transition with the infralobular segment) and the lateral genu (the transition to the lateral crus). It is these two genu that bracket, and therefore create the anatomy of the “domal notch”. The lateral crura are made up of the lateral crus and accessory cartilages. The lateral crus is the main component of the nasal lobule. Medially, the lateral crus–domal junction line determines tip definition. Cephalically, the lateral crus has a scroll formation adjacent to the upper lateral cartilages. Caudally, the inferior border of the lateral crus diverges away from the nostril rim. Laterally, the crus passes away from the nostril rim and tapers in size. Configuration, axis of orientation and axis of curvature of the lateral crus all affect its aesthetic fabric.

Fig. 39.1 A&B, Anatomy of the tip.

With kind permission from Springer Science & Business Media: Daniel R. Rhinoplasty: An atlas of Surgical Techniques. 2002.

The nasal base

The nasal base is not a distinct anatomical entity; its aesthetic is frequently impacted by adjacent tip structures. The nasal base is subdivided into eight separate components (Fig. 39.2). The columella base consists of soft tissue, depressor septi nasalis muscle centrally, the nasalis muscles laterally and the medial crural footplates. The transverse width of the columella base is related to the separation of the footplates and the quantity of intervening soft tissue. The central columellar pillar is created by medial crura apposition; its length determined by the medial crura termination at the columellar lobular junction. The infralobular triangle and soft triangle are the capstone of the basilar pyramid and are determined by the configuration of the middle crura. The soft triangle is a reflection of the width of the domal notch and is comprised of a web of opposed skin and vestibular mucosa, which is devoid of cartilage. The lateral wall reflects the support and proximity of the lateral crura to the alar rim. The alar base is composed of subcutaneous tissue and muscle and serves as an external baffle for the nose, which determines the amount of alar flare and width. The nostril sill varies widely on its vestibular and cutaneous surfaces, and is intimately affected by the configuration of the adjacent alar base. The nostril is the central void that is determined only by its surrounding structures and is highly variable between individuals.