Secondary rhinoplasty

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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.

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 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.

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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.

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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.

Technical steps

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.

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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.