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 tip

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.

Fig. 39.2 A–D, Nasal base components.

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

Assessing the septum and turbinates

The importance of accurate evaluation of the septum in the secondary nose cannot be overstated. Septal surgery can consist of septoplasty (resection and relocation) for treating deviations, or septal harvest for graft materials. While it is crucial to establish the dorsal line before harvesting the septum, in secondary noses the septum frequently has been partially (and possibly maximally) harvested during the prior operation(s). Assessing the septum early is essential for three reasons. First, it clarifies any questions about the presence or absence of support. Second, it defines the existence of persistent septal deviations or prior surgical misadventures. Third, it allows the surgeon to establish the availability of septal cartilage to be harvested for graft material at the outset.

Following Betadine preparation and subperichondrial injection with 1% Xylocaine with epinephrine, a right vestibular hemi-transfixion incision is performed and the caudal septum is identified. Sharp dissection with a Converse–Daniel scissor is performed down to the perichondrium. In order to facilitate the dissection and guarantee that you are in fact in the subperichondrial plane, cross-hatches are made on the caudal septum and then a Cottle elevator is used to elevate the mucoperichondrium and reveal the Robin’s-egg blue color beneath. The elevator is inserted dorsally parallel to the septum and a vertical sweep is done back and over the perpendicular plate of the ethmoid, and then down onto the vomer (Fig. 39.3). The inferior portion is then dissected from back to front coming from the posterior vomer forward, allowing easier separation of the fused perichondrial/periosteal fibers. If the septum has been previously harvested, this dissection is done only over the dorsal aspect of the L-strut. One must be careful separating the mucosa–mucosa adherence if the septal body has been previously harvested. If still present, cartilage harvest is accomplished with a #15 blade, septal scissors and a Cottle elevator taking great care to preserve at least a 10 mm wide L-shaped strut. If a dynamic septal collapse is present, then septal replacement grafts must be considered.

Fig. 39.3 A–D, Assessment of the septum.

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

Once all septal surgery has been completed, attention can be turned to the turbinates. Although turbinate hypertrophy is a common additional cause of airflow restriction, caution must be exercised with turbinate resection. Most turbinate enlargement can be adequately treated with either out-fracture or judicial partial submucosal resection.

Opening and assessing the skin envelope

Fig. 39.4 A&B, Transcolumellar incision.

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

Defining the existing, or non-existing alar anatomy and internal lining

Intrinsic problems with secondary tips generally fall into two categories that are split fairly equally in incidence: acts of omission and acts of commission. In the former, the prior surgeon “underoperated”, leaving alar cartilages that are still too large, too bulky, mis-shapen or mis-oriented. In the latter, the prior surgeon either “over-operated” on the alar cartilages, or failed to recognize their inherent weaknesses. In these patients, the alars are often too narrow, collapsed or buckled, disjointed or separated, over-rotated or under-supported. It is this group of patients who frequently require aggressive grafting with columellar support grafts, integrated or on-lay tip grafts, or with alar support or extender grafts.

Defining the dorsum

Decisions about dorsal modification involve determinations about dorsal height (reduction, augmentation or preservation), nasal width (narrower, wider, or asymmetric correction) and length (shorter or longer). Most secondary dorsums have already been reduced at the previous operation(s), but may have been overly resected (saddle nose) or inadequately resected. A common error of commission during the primary procedure is inadvertent under-resection of the anterior septal angle. This occurs simply due to the downward inclination of the scissors or knife toward the keystone area; some refer to this postoperative bump as “the horn of woe”. The dorsum that was previously over-resected will frequently require augmentation to restore the ideal profile. Various materials can be utilized for this purpose (septal cartilage, conchal cartilage, Surgicel, crushed cartilage, Medpor, etc.), but the authors prefer diced cartilage either alone, or more commonly wrapped in a smooth envelope of deep temporal fascia.

Providing support: spreader grafts, extension grafts and columellar struts

Spreader grafts

Spreader grafts are matchstick-sized pieces of cartilage placed between the septum and the upper lateral cartilage that are used to restore the normal dorsal width of the septum which is lost during dorsal reduction (Fig. 39.5). In addition to holding open the internal valve, they can also help to correct existing asymmetries of the dorsum, and correct or prevent an “inverted-V deformity” as seen on the anterior view. Creating spreader grafts that are larger on one side than the other will help achieve balance of the dorsal lines, and can bracket the dorsal septum, helping to straighten it somewhat. Spreader grafts also come into play when they serve as a strong neo-base on which to place augmentation grafts.

Fig. 39.5 A–D, Spreader grafts.

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

Osteotomies: when, where and how?

The purpose of lateral osteotomies is to narrow the base bony width of the nose. Medial oblique osteotomies, in contrast, narrow the wide nasal dorsum. Although many surgeons obtain excellent results with percutaneous osteotomies, the authors prefer an endonasal approach. The two most common methods are the low-to-high and low-to-low osteotomies (Fig. 39.6). The low-to-high osteotomy begins at the pyriform aperture on the nasal process of the maxilla and passes tangentially across it to the nasal bone suture line at the level of the medial canthus. Subsequent digital pressure on the lateral wall results in a greenstick fracture of the transverse portion and a gentle tilt of the lateral nasal wall. In the low-to-low osteotomy, first a transverse osteotomy is done with a 2 mm osteotome placed through a small vertical stab incision just above the medial canthus. Then, a low-to-low lateral osteotomy is performed with a straight osteotome beginning at the pyriform aperture on the nasal process of the maxilla and passing straight up the lateral wall to end at the level of the medial canthus. Here, a slow but forceful 90 degree rotation of the osteotome (with the blade against the maxilla) produces complete inward mobilization of the lateral wall and subsequent nasal narrowing.

Fig. 39.6 A–H, Osteotomy methods and markings.

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

The tip: suturing and grafting

The technique used for tip modification depends largely on the particular tip problem and degree of integrity of the tip cartilages. Sutures are favored whenever shaping alone can achieve the desired goal; grafts are used when the alar cartilages are inadequate or deformed. With rare exception, a strong columellar strut will be inserted in all secondary cases (unless one was placed previously and is of adequate size and strength). The strut provides the foundation upon which the alar cartilages are sewn, followed by optional tip grafts. The manner in which the alars are secured to this strut will ultimately determine the tip projection and degree of rotation.

Suturing

The domal creation suture is a medially tied asymmetric horizontal mattress suture of 5-0 PDS placed at the domal segment which is defined by the “domal notch” on the caudal border of the middle crura (Fig. 39.7). When placed correctly this suture will produce a curl, juxtaposing a convex domal segment next to a concave lateral crura. The domal equalization suture is passed through the cephalic portion of each domal segment, narrowing the inter-domal distance and ensuring symmetry. If additional upward tip rotation is needed, a 4-0 PDS tip rotation suture can be placed, essentially hitching the columella-crura complex to the dorsal septum just above the anterior septal angle.

Fig. 39.7 Domal creation suture (A, B). Domal equalization suture (C, D).

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

Grafting

The popularity of closed tip grafting (both on-lay and multilayer grafts) in secondary rhinoplasty has declined with the increasing application of open secondary surgery. On-lay grafts usually are designed from concha and placed through an infra-cartilaginous incision. To avoid displacement (even in appropriately created small pockets), a double-armed 5-0 plain gut suture is placed through the graft in a “U” fashion and then the needles are brought retrograde through the skin at each dome point to both guide and secure the graft. The multilayer tip graft (aka Sheen shield graft) is most frequently used in closed cases when a patient presents with a flattened infra-lobule. The graft is composed of several layers, with a solid ethmoid buttress graft at the base, followed by solid grafts to set the dome points and then covered with bruised and crushed cartilage grafts to provide more infra-lobular fill. For open tip grafting, the most commonly used graft is a tapered modification of the shield graft that looks more like a golf-tee and is 1–12 mm wide cephalically, only 4 mm wide caudally and about 15–18 mm long. The graft can be integrated into the divergent middle crura so that the tip is accentuated and lies just slightly above the domes (Fig. 39.8). Noses with thicker skin or with a poorly defined tip sometimes require that the graft be projected above the domes. This creates more projection and definition, but should be supported by a backing cap graft when it lies more than 2 mm above the top of the domes.

Fig. 39.8 A–C, Open tip grafts.

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

Altering the base and vestibules: rim grafts, composite grafts, and sill excisions

For patients with retracted alar rims, with alar rim notching following aggressive resection of the lateral crura, or with a high potential for developing these problems, alar rim grafts and composite grafts are very effective. For minor deformities of 1–2 mm, cartilage only grafts are used effectively and can even be placed prophylactically in patients with arched nostril rims. Rim grafts measure 10–14 mm in length and 2–4 mm in width. A 4 mm incision is made posterior and parallel to the alar rim and then a blunt tipped tenotomy scissor is used to dissect a subcutaneous pocket. The graft is inserted into the pocket and the incision is closed with 4-0 plain gut suture, carefully passing the closing suture through the graft to help prevent graft migration. For rim retraction that exceeds 2 mm, composite grafts should be employed.

Alar base modification should be carefully planned and conservatively executed; overly aggressive excisions can be disastrous. In secondary cases, two possible indications exist: the patient should have had (but did not have) alar base excision during the first operation, or the patient has had poorly performed resections. One must very carefully inspect the nostril apices to ascertain what type of excision was performed originally and approach any alar base revision with great caution. The decision about the type and amount of excision is based upon nostril shape, sill width, degree of alar flare, and alar width in relation to the inter-canthal width. Alar width is measured at the alar crease; alar flare is measured at the widest point of the alar. The critical decision to make is whether the alar width is greater than inter-canthal width preoperatively or will become greater as dorsal support and tip projection are reduced intra-operatively. For nostril sill excisions, a 2.5–3.5 mm wide inverted trapezoid is drawn with vertical sides that then triangulate to a point inside the vestibule in a fashion similar to a lip excision (Fig. 39.9). Following excision, sill closure is performed with a 4-0 plain catgut that everts the edges; the skin is closed with a 6-0 nylon. Alar wedge excisions are carefully marked with calipers and then injected with local. A single hook stabilizes the portion to be excised while the skin is carefully cut, taking care to avoid the underlying mucosa (Fig. 39.10). When combined excisions are performed, the supra-crease alar line of incision (the more caudal line of incision) extends around the base to the medial vertical component of the nostril sill excision. The lateral sill excision should be drawn narrow (2–3 mm) before widening out to the 3–4 mm alar wedge component. This “L-shaped” combined excision then tapers as it extends laterally (Fig. 39.11).

Fig. 39.9 A&B, Nostril sill excision.

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

Fig. 39.10 A&B, Alar wedge excision.

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

Fig. 39.11 A–F, Combined sill/alar excision steps and suturing.

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

Ear grafts (conchal and composites), rib grafts and deep temporal fascia

Harvesting conchal grafts is simple and begins by generous betadine prep followed by infiltration with 5 mL of 1% lidocaine with epinephrine both anteriorly and posteriorly. The anterior line of the conchal bowl is transferred posteriorly with methylene blue and a 25-gauge needle. With the ear helix retracted forward, a longitudinal incision is made above the blue marks. The cartilage is incised below and the anterior skin is elevated centrally. Once completely elevated, the entire conchal bowl can be removed. Following hemostasis, the incision is closed with a running, locking 5-0 plain gut suture and then a tie-over bolster of xeroform gauze is applied (Fig. 39.12).

Fig. 39.12 A–F, Conchal graft harvesting.

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

Composite grafts are used for three primary indications: (1) alar rim lowering; (2) correction of vestibular stenosis; and (3) internal valve reconstruction. The most common donor site is the anterior surface of the ipsilateral concha cymba. The anterior undersurface of the cephalic helical toot can be used in tough cases where previous ear grafts have already been utilized. Careful traction on the helical root and antihelix exposes the hidden medial extent of the concha cymba. The required graft size is drawn in an ellipse shape, carefully planning the needed amount of skin. The donor site can usually be closed primarily so long as the width of skin excised remains under one centimeter. Wide skin undermining facilitates closure with 4-0 plain gut horizontal mattress sutures which incorporate the centrally underlying post-auricular soft tissue.

Rib grafts (either costo-chondral or osteo-chondral) are used in patients who require strong support and have inadequate amounts of septal or conchal cartilage available.

For costo-chondral graft harvest, the patient is placed supine and a 3–4 cm incision is made over the junction between the floating 9th rib tip and the 8th rib (Fig. 39.13). Dissection is carried down through the external oblique muscle. For a 9th rib graft, the mobile, medial cartilaginous tip is identified and dissected extra-perichondrally in a retrograde fashion. Since it is a “floating rib”, the extraperichondrial dissection is extremely quick with a total harvest time of less than 20 minutes in most cases. For the 8th rib, sub-perichondrial hydrodissection is performed with lidocaine 1% with 1 : 100,000 epinephrine. Serial “H” incisions are cut through the ventral perichondrium to allow a sub-perichondrial dissection. The rib is freed from the caudal aspect of the 7th rib (at the syncytium) and then dissected in a retrograde fashion to the bony–cartilaginous junction under direct vision. After the rib is cut and removed, a pleural integrity check is performed. The wound is closed in layers. A cantilevered osteo-chondral rib graft harvest is utilized if a dorsal replacement graft is needed to support a severely shrunken skin envelope as occurs typically in the cocaine nose. The patient is placed into the lateral decubitus position on a bean-bag. The incision may need to be located slightly more lateral for the cartilage only graft. The lateral portion of the osseous rib is first dissected with a Doyen to allow rib division. Then anterograde dissection is performed toward the medial cartilaginous portion.

Fig. 39.13 A–D, Rib harvest.

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

Deep temporal fascia can routinely be harvested through a 2.5 to 3.5 cm incision in the scalp, anterior to the auricle and directly overlying the temporalis muscle belly. Following marking and injection with lidocaine with epinephrine, sharp dissection is performed through the superficial temporal fascia, down to the shiny deep temporal fascia. An incision of appropriate size and configuration is made with a #15 blade in the deep temporal fascia to reveal the underlying muscle, and then carefully elevated off of the muscle while the more superficial scalp layers are carefully retracted. Care should be exercised as the fascia is elevated off of the middle temporal vessels (Fig. 39.14).

Fig. 39.14 A–D, Harvesting fascia.

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