PRIMARY RHINOPLASTY

INTRODUCTION

For a successful rhinoplasty, identifying and understanding the indications for surgical intervention, whether cosmetic, functional or both, evaluating the patient – what are their motivations and expectations and are they appropriate candidates for rhinoplasty are very important. To understand the normal anatomic relationships, obtain a detailed history and perform a thorough physical exam and to  develop a systematic approach for evaluating each patient’s particular features are pivotal

To know limitations, to develop a formal plan with alternatives based on the clinical evaluation and informing the patient of the plan and be thorough in your preparation, choosing the operative approach (open versus closed) based on the patient’s requirements are essential. A standardized postoperative plan and making it clear to the patient, being cognizant of potential complications and address them when necessary, are most important steps.

The surgeon relies on his or her aesthetic sense to craft a result that will produce a balanced, harmonious nose in relationship to the rest of the face. The initial operation is critical to the long-term result in primary rhinoplasty, because the tissues are virginal and undistorted by prior operative procedures.

INDICATIONS

Functional,

  • Nasal airways obstruction:
  • Congenital
  • Traumatic

Reconstructive,

  • Post traumatic
  • Congenital

Cosmetic,

  • Desire to change shape of nose:
  • To change self-image
  • To create oren asal harmony

The indications for rhinoplasty fall along a spectrum from purely functional to purely cosmetic. The patient who undergoes rhinoplasty for cosmesis stands to benefit with respect to self-image and self-esteem after a successful rhinoplasty.

There can be great advantages to the patient when rhinoplasty is performed for functional reasons. An example is airway obstruction which can be significantly improved if not totally eradicated. Whether the etiology is congenital or traumatic, patient satisfaction can be substantial after corrective surgery. 

PREOPERATIVE HISTORY AND CONSIDERATIONS

PATIENT FACTORS

When initially assessing a patient for potential rhinoplasty, the surgeon should concentrate on evaluating the patient’s desires and expectations prior to performing the comprehensive facial analysis. Although there are different methods for integrating the patient into the surgical process, we find that computer imaging provides an excellent way for patients to gain a realistic understanding of the anticipated outcome. Although the images are not a guarantee of surgical results, they do provide a visual representation and a means for patient education. These images, combined with standardized anterior, lateral, oblique, and basal photographs, provide the basis for the preoperative surgical plan.

NASAL HISTORY

A full and complete nasal history should be obtained. This includes a prior history of:

  • Trauma;
  • previous nasal, septal or sinus operations;
  • allergies;
  • sinus problems;
  • tobacco use;
  • illicit drug use.
  • A list of current medications
  • Nonsteroidal anti-inflammatory agents and certain herbal supplements may increase bleeding complications after surgery and should be discontinued at least 7–10 days prior to rhinoplasty.
  • Patients are instructed to avoid consumption of salicylic derivatives for 3 weeks prior and 1 week following surgery.

ANATOMIC FEATURES

Having determined that the patient is an appropriate candidate for surgery, the next element to proper preoperative surgical planning is critical facial analysis. Each individual nose has different proportions, morphology, and relative relationships with the surrounding face. To preserve nasofacial harmony, it is crucial to perform a systematic and meticulous analysis of the nose and face. Accurate diagnosis of the deformity(s) determines the optimal surgical plan for correction. The surgeon should point out natural facial asymmetries preoperatively so that the patient gains a better under- standing of what is present before any operative intervention.

  1. Skin type:

The native skin quality influences the operative plan and subsequent techniques performed. First, skin type, thickness, and texture are assessed. Thicker skin will tend to camouflage changes to the underlying osseocartilaginous framework, and may therefore allow a more ‘aggressive’ surgery to demonstrate an appreciable change. Patients who have thicker skin that has a more sebaceous character tend to have more postoperative edema, especially in the tip or lobule area.

Thinner skin tends to reveal even minor changes to the underlying framework. Therefore patients who have thinner skin can be more challenging because there is less margin for error.

  1. Systematic analysis of the nose and face:

Systematic analysis of the nose and face is undertaken, potential anomalies of the underlying facial skeleton are evaluated. Initially we evaluate potential anomalies of the underlying facial skel- eton, including the maxillomandibular relationship.

We divide the face into thirds using horizontal lines adjacent to the:

  1. hairline;
  2. brow (at the level of the supraorbital notch);
  3. nasal base;
  4. memton
  5. Nasal features:

 Frontal view,

  •  Nasal deviation is evaluated by drawing a line from the mid-glabellar area to the menton, bisecting the nasal ridge, upper lip, and Cupid’s bow.
  • The nasal dorsum is then assessed.
  • A relationship between the bony base width and the alar base is then assessed. Males tend to have a wider bony base than females and it is important not to over-narrow the male dorsum creating a feminized result.
  • Next the alar base and alar rim are analyzed. The alar rims should also be assessed for symmetry, and should flare slightly outward in the inferolateral direction.
  • The tip is assessed
  • The final assessment on frontal view is of the outline of the alar rims and the columella,

  1. Basal view and Lateral view,

  • The basal view of the nose is addressed next, the nostril itself should have a teardrop-like geometry, with the long axis from the base to the apex oriented in a slight medial direction.
  • The lateral view is then analyzed, beginning with the position and depth.

TIP PROJECTION

Tip projection is addressed on the lateral view.

DORSUM

The dorsum is then analyzed.

SUPRATIP BREAK

The degree of supratip break is appraised when the nasal tip projection and dorsum are evaluated. A slight supratip break is preferred in women but not in men. This gives the nose more stinguishes the dorsum from the tip.

TIP ROTATION

The nasolabial angle is used to determine the degree of tip rotation.

  • Alar-columellar relationship (lateral and frontal views),
  • The alar-columellar relationship is then assessed.

DIFFERENCES BETWEEN MALE AND FEMALE NOSES

  • Dorsum tends to be straighter and wider with decreased concavity,
  • Nasal dorsal profile is different,
  • No supratip break,
  • Tip rotation slightly less,
  • Stronger chin abutting the plumb line,
  • Broader, more bulbous, nasal tip, in general,
  • Skin is usually thicker, masking the amount of change that can be perceived.
  • The male face tends to have a squarer, less rounded appearance, with stronger

more pronounced features.

INTRANASAL EXAM

An intranasal exam completes the preoperative analysis. This is performed with a nasal speculum, headlight, and vasoconstriction. The septum, turbinates, and internal nasal valve are evaluated for obvious deformities or pathology.

PATIENT COUNSELING

  • After the initial history and physical examination, the procedure is fully discussed with the patient.
  • The risks and benefits of the procedure are detailed, and all questions answered.
  • The patient is provided with a written, detailed estimate of surgical charges with complete explanations.
  • The deformities are reiterated, questions answered, and the consent reviewed and signed.
  • Preoperative and postoperative instructions sheets and a list of medications to be avoided are also provided.

OPERATIVE APPROACH

RELEVANT ANATOMY:

A complete knowledge of anatomy is paramount to obtaining the superior result. The nose is divided into:

  • External skin and soft tissue, The thickness, mobility, and sebaceous character of the nasal skin, some ethnic subgroups, such as Africans, Hispanics, and those of Mediterranean descent, can have thicker, more sebaceous skin.
  • Bone and cartilage,
  • Ligamentous support.
  • Muscles,
  • Blood supply,
  • Nasal vaults,
  • Nasal function,

The septum, turbinates, and nasal valves (internal and external) serve as the anatomic functional foundation for the nose, contributing to respiration, filtration, humidification, temperature regulation, and protection.

INCISIONAL APPROACHES:

 The two basic incisional approaches to rhinoplasty are:

  • The open technique;
  • The closed (endonasal) technique.

Open approach:

The open approach involves a transcolumellar incision, The open approach also involves skeletonizing the underlying osseocartilaginous framework, which gains enormous exposure for the manipulation and correction of deformities.

Closed approach (endonasal):

The closed technique can be performed using a cartilage-delivery approach or a nondelivery approach.

Open versus closed approach:

I perform open approach in my practice,

Advantages:

  • Provides excellent exposure and control,
  • Allows evaluation of complete deformity without distortion, manipulation of the osseocartilaginous framework under direct binocular visualization,
  • Allows use of both hands,
  • Has minimal negative consequences, aside from the external scar and occasional prolonged tip edema, which resolves in virtually all patients and is not an issue provided the expectation level is set preoperatively,
  • Allows for predictable and reproducible results,
  • The increased accuracy and versatility of the open approach results in a negligible external scar. Patients rarely object to the transcolumellar scar because it is usually invisible at conversation distances.
  • Open approach is appropriate for secondary rhinoplasties and post-traumatic rhinoplasties.
  • Direct control of bleeding with electrocautery
  • Suture stabilization of grafts (invisible and visible)

Potential disadvantages:

  • External nasal incision (transcolumellar scar)
  • Prolonged operative time
  • Protracted nasal tip edema
  • Columellar incision separation
  • Delayed wound healing

Closed (Endonasal) approach:

Advantages:

  • No external scar
  • Limits dissection to areas
  • Promotes healing by maintaining vascular bridges
  • Produces minimal postoperative edema
  • Reduces operating time
  • Results in fast patient recovery time

Disadvantages:

  • Prohibits simultaneous visualization of surgical field by teaching surgeon and students
  • Does not allow direct visualization of nasal anatomy
  • Makes dissection of alar cartilage difficult, particularly in cases of malposition

OPERATIVE TECHNIQUE

Preparation for surgery

  • On the morning of surgery, any final questions are answered.
  • The patient is taken to the operating room and positioned supine on the operating table.
  • Noninvasive hemodynamic monitoring devices are placed, and all pressure points are padded appropriately.
  • Cefazolin 1 g is administered intravenously as a perioperative antibiotic.
  • We prefer general anesthesia for our patients,

INCISION

Open approach major phases:

  1. In the open approach I use a stairstep transcolumellar incision across the narrowest portion of the columella. The stairstep is important because it helps to provide landmarks for accurate closure, prevents linear scar con- tracture, and camouflages the scar.
  2. Bilateral infracartilaginous extensions are then performed,
  3. Skin envelope dissection is done,
  4. The osteocartilaginous hump is reduced,
  5. Septal reconstruction/cartilage graft harvest,
  6. Inferior turbinoplasty,
  7. Cephalic trim,
  8. Placement of spreader grafts,
  9. Tip modification,
  10. Tip grafts, If more tip projection or definition is desired after the preceding maneuvers, tip grafts may be used,
  11. Correcting the alar–columellar relationship,
  12. Osteotomy techniques,

Osteotomies are a powerful technique in rhinoplasty.

The indications:

  • To narrow the lateral walls of the nose;
  • To close an open-roof deformity (after dorsal hump reduction);
  • To create symmetry by straightening the nasal bony framework.

Contraindications to osteotomies can include:

  • Patients with short nasal bones;
  • Elderly patients with thin, fragile nasal bones;
  • Patients with heavy eyeglasses.
  • Closure,
  • Alar base surgery,

If alar base surgery is necessary, it is generally performed after closure of the transcolumellar and infracartilaginous incisions, but before intranasal and external splints are placed. Alar base abnormalities include:

  • wide or excessive
  • nostril sills, a wide alar base, asymmetric or
  • malpositioned alar bases, or any combination of these.

COMPLICATIONS AND SIDE EFFECTS

The most frequent ones:

  • Further tip refinement or correction of tip asymmetries,
  • Pinched supratip deformity,
  • Excessive dorsal reduction or dorsal irregularities,
  • Continued nasal airway obstruction,
  • Infection,
  • Intra and postoperative bleeding are associated with consumption of anti-inflammatory medications or inherited coagulopathy,
  • Most rhinoplasty patients experience temporary numbness of the nose tip,
  • Anosmia and lachrymal duct injury,

POSTOPERATIVE CARE

  • All preoperative and postoperative instructions are given to the patients in writing before and on the day of surgery.
  • Prophylactic antibiotics, analgesics, nasal saline solution for postoperative nasal congestion are administered.
  • The patient is instructed to keep the head of the bed elevated at an angle of 45º beginning immediately after surgery to help minimize postoperative swelling.
  • Cool compresses are used periorbitally during the day for the first 48 hours.
  • Any manipulation of the nose, including rubbing, blotting, or blowing, is discouraged for the first 3 weeks postoperatively.
  • Sneezing should be done through the mouth during this time.
  • It is imperative to keep the nasal splint dry,
  • We maintain our patients on a liquid diet on the day of surgery, which is subsequently advanced the following day to a soft regular diet.
  • During the first 2 weeks, nasal congestion may be minimized by the use of normal saline nasal spray and over-the-counter nasal sprays such as oxymetazoline.
  • We ask the patient to return 7 days postoperatively, at which time the sutures and nasal splints are removed.
  • The nose (especially the tip) may appear swollen and turned up, and the tip may feel numb, but the patient is reassured that this is to be expected and will resolve with time, with normal sensation returning within 3–6 months.
  • The patient cannot let anything, including eyeglasses, rest on the nose for at least 4 weeks.
  • Glasses should be taped to the forehead. Contacts can be worn as soon as the swelling has diminished enough to allow easy insertion.
  • We ask our patients to avoid contact sports and restrict strenuous activity that increases their heart rate (above 100 beats/min) or blood pressure for 3 weeks after surgery.
  • The patients are instructed not to make any judgments about the nose until 1 year after surgery.
  • After the first postoperative visit (within the first week), the patients are seen 1, 3, and 6 months postoperatively and yearly thereafter.