Raj Kanodia MD, FACS , Anil R. Shah MD, FACS
Rhinoplasty is the most challenging operation in plastic surgery. First of all, the anatomy in each nose is distinct. The wide amount of variation is seen in part due to differences within skin soft tissue envelope thickness and the shape and orientation of the nasal cartilages and bones. In addition, each of the nose’s constituent parts are intricately related to the other so that a small change in one component can lead to dramatic changes elsewhere, thereby creating a large impact upon the nose. Another obstacle in rhinoplasty is the technical demands that the operation imposes. No where else in plastic surgery is the margin upon which success hinges so slim, that a millimeter can spell the difference between a successful result or disappointment. Finally, manipulation of the form of the nose requires an artistic vision and sense of proportion and dimension. While there may be an aesthetic ideal for other operations, the ideal nose for one face may be completely different for another face, necessitating a keen aesthetic judgment by the surgeon.
Amongst rhinoplasty surgeons, there is a wide range of techniques, philosophies and surgical results. Most surgeons employ an “ideal nose strategy” for rhinoplasty. These surgeons have a vision of a perfect nose and focus their rhinoplasty efforts toward creation of their ideal nose for every face. Unfortunately, the “ideal nose strategy” has a few flaws. First of all, this strategy assumes that all parts of the nose which do not meet the criteria of this ideal nose need to be changed. The authors contend that there is a wide range of features which may be attractive and must be considered in the context of the remainder of the face and nose. Surgeons who ascribe to the ideal nose strategy will often employ more extensive radical procedures with extensive grafting in an effort to impart more dramatic changes to the nose. While the surgeon may be able to achieve their goal in changing one aspect of the nose, it often comes at the expense of unintended changes in the remainder of the nose. Another downside with the ideal nose strategy is the one nose fits all strategy will lead to imbalance between nose and the corresponding facial features. A successful rhinoplasty operation is a marriage between the face and nose so that not only is the appearance of the nose improved, but the remainder of the facial features are enhanced.
Rather than ascribe to the notion that all noses should like similar (the ideal nose strategy), the authors ascribes a philosophic approach that attempts to maximize the beauty within each nose. The senior author has developed a philosophy emphasizing a collection of subtle changes to the nose as a means to maximize both its function and natural appearance. A central tenant to this philosophy is to respect the complexity of the nasal anatomy. Each constituent part of the nose is interrelated, whereby small changes in one part of the nose may create untoward subsequent changes in other parts of the nose. To add further complexity to the equation, time provides an additional dimension where additional changes may manifest within the nose.
The authors philosophy is based on twenty eight years experience and over 5,000 rhinoplasty patients . The aesthetic goals of the operation are to create subtle, artistic refinements which will continue to improve during the healing continuum. While other surgeons may try to forceably manipulate each nose to look like an “ideal nose”, the authors contend that soft, subtle changes to the existing nose will lead to a more natural looking nose and harmoniously achieve facial balance. Many of these small changes will continue to improve with time resulting in further refinement of the nose.
The senior author’s approach to nasal tip definition is classified under the broad category of transcartilaginous techniques, where the lower lateral cartilages are shaped through direct excision and removal of excessive lower lateral cartilage bulk. (1) Traditionally, these techniques have been separated into two categories, retrograde excision of cartilage and direct excision. The transcartilaginous approach offers several distinct advantages. First of all, this technique is the least disruptive technique available. The only major tip supportive mechanism effected is the relationship between the lower lateral cartilages and the upper lateral cartilages. (2) However, the underlying anatomy of the nose, including the vestibular mucosa, is left for the most part undisrupted, which translates visually into results which maintain the natural features of the nose. While other techniques may leave behind a footprint of a rhinoplasty such as a columellar scar, asymmetry of the alar rim, or loss of the highlights of the soft tissue facets, the “Kanodia approach” provides visual improvements while minimizing the potential stigmata of rhinoplasty. When properly executed, the integrity of the lower lateral cartilage is preserved, providing a natural shape to the lower lateral cartilage. Over time, further nasal tip refinement is seen in the nasal tip, as the skin over the nasal tip continues to mold.
Whenever a rhinoplasty surgeon decides to perform a particular surgical maneuver, it may hold serious, aesthetic consequences for the patient. For example, suture techniques can exacerbate internal recurvature of the lower lateral cartilages, creating potential airway blockage. Over time, the suture technique can result in bossae and knuckling. Suture techniques can also lead to nostril asymmetry, notching of the ala, loss of the soft tissue triangle facets, unnatural contours to the nose, and alar depressions. Additionally, suture techniques can result in a pinched nasal tip, an obvious stigmata of a rhinoplasty.
The transcartilaginous technique has a significant advantage of minimizing soft tissue edema. While the open technique and suture methods will require dissection over the nasal domes, the soft tissue of the nasal tip is left relatively undisturbed with the trancartilaginous operation. The larger amount of supratip swelling associated with other techniques can lead to less than desirable outcomes including an overly round nose and pollybeak formation. Many surgeons have attempted to compensate for this additional swelling by overprojecting the nose, making the entire nose larger. Most patients seeking primary rhinoplasty do not want their nose larger, but instead are seeking a less extreme version of their existing nose.
A purported potential disadvantage of the transcartilaginous technique is the steep learning curve associated with it. This technique requires the ability to interpret the underlying lower lateral cartilage anatomy without direct visualization. A combination of visualization, palpation and experience are necessary tools to perform this technique. In addition, the surgeon must be able to determine if the amount of cartilage excised was symmetrical and exact in nature. Another obstacle in learning the transcartilaginous approach is the ability to make small changes to control nasal tip projection and rotation. It is the authors contention that every technique in rhinoplasty has a steep learning curve and that the transcartilagionous technique significantly limits the potential complications as opposed to other more aggressive techniques.
All patients are evaluated in person by the physician. While, the Internet and email are continuing to revolutionize the practice of medicine, electronic photographs can not replace a thorough intranasal exam and palpation of the lower lateral cartilages and nasal tip support. Anterior rhinoscopy allows for evaluation of the nasal septum and any deflections which may need to be addressed during the operation. Palpation of the anterior portion of the septum can help determine the contribution of the septum to projection and rotation. During the initial consultation, an understanding between the surgeon and patient is necessary to see if the patient and surgeon have a shared goal of what can be achieved.
Preoperative preparation of the patient plays a significant role in creating the setting of a successful operation. First of all, preoperative icing is performed on all patients. Ice acts as a natural and powerful vasoconstrictor of the nose, which significantly reduces edema, swelling, and bruising. Low doses of preoperative Valium and Demerol help to relax patients and thereby release less stress hormones such as cortisol which can lengthen the recovery process.
2% ponticaine pledgets are placed against the intranasal mucosa in order to locally anesthetize the field. Patients are initially injected with a solution of .5% ropivicaine and 1% lidocaine with epinephrine 1:200,000 in a ratio of 1:1 along the soft tissues of the nose and septal mucosa. Fresh epinephrine is preferred due to a longer lasting effect intraoperatively and quicker onset of action than premixed lidocaine and epinephrine. A common mistake of neophyte surgeons is utilizing too much volume with local anesthesia, thereby obscuring the nasal form of the nose.
Accessing the septum:
Initially, a hemitransfixion incision is made 5 mm posterior to the membranous septum. The posterior location of the incision conceals visibility of the scar from the lateral view. In addition, the farther posterior location is less likely to disrupt nasal tip support as opposed to a hemitransfixion or full transfixion incision. The septal mucoperichondrium is then retracted with a brown forcep and initially elevated with a Woodson elevator. If cartilage grafting is needed, septal cartilage can be harvested along the nasal floor just above the vomer with a septal knife. Frequently septal cartilage along the floor will cause deviation and airway obstruction and is removed to improve nasal function. Further septal deviations are addressed at this time as well including deflections of the perpendicular plate, spurs along the nasal floor.
If manipulation of the anterior septum is required, a retrograde septal mucosal approach is utilized with a spreading motion of the gooseneck dissecting scissors. If exposure of the nasal spine or depressor septi muscle is needed, a Parkes retractor can be utilized. Changes in projection and rotation of the nose can be performed by changing the length and shape of the caudal septum. Deprojection of the nose and rotation can be performed by precise resection of the anterior septal angle. A caudal septal shave will in part lead to slight shortening of the nose. Counterotation can be performed by an excision of the posterior septal angle.
Addressing the nasal tip:
The lower lateral cartilages are addressed by a transcartilaginous approach. The surgeon must be able to accurately predict how much cartilage must be excised and how much left behind in order to achieve the desirable aesthetic outcome and prevent untoward sequlae. A two pronged retractor is used to retract the nostril and the forefinger is utilized to present the lower lateral cartilage into view. An incision is first made through the vestibular mucosa only along the midportion of the lower lateral cartilage, 6 to 9 mm superior from the alar rim.
The vestibular mucosa is bluntly elevated superiorly during the excision, allowing for exposure of the lower lateral cartilage. An incision is made with a 15-C scalpel on the lower lateral cartilage outlining the caudal extent to be resected. Gooseneck scissors are used to dissect the soft tissues from the lower lateral cartilage in a supraperichondiral plane to the cephalic edge of the lateral crus. The superior portion of the lower lateral cartilage, including a portion of the lateral lower lateral cartilage, intermediate lower lateral cartilage, and medial lower lateral cartilage is excised. Once the cartilage has been excised, the lower lateral cartilages are inspected externally and visual changes of the shape of the nasal tip are inspected, preserving an intact strip of lower lateral cartilage. (see diagram) The lateral portion of the lower lateral cartilage is preserved, preventing potential alar collapse and unsightly alar pinching. Vestibular skin in this area is treated with the utmost care and is preserved.
Through the transcartilaginous incision, the scroll area can be visualized. Precise excision of the cephalic scroll allows for further definition of the nasal tip. In addition, the scroll area can allow for further space for rotation of the nasal tip.
Adjusting the nasal dorsum:
Through the same transcartilaginous incision, the dorsum is skelotonized supraperichondrially and periosteally. The nasal dorsum is visualized with the aide of a Parkes nasal retractor. The dorsal septal cartilage is excised in a precise, deliberate manner with a 15-C blade in a cephalic to caudal manner. Dorsal convexities can be addressed with a gouge. The overlying surface of the nasal bones is denser cancellous bones, making it more resistant to nasal rasping. Precise removal of nasal humps with a gouge can be performed to “uncap” the nasal bones and allow for medial movement of the nasal bones. Different gouges are used depending on the length and height of bone to be uncapped and opened.
A main advantage of endonasal technique versus external rhinoplasty is dorsal profile adjustments. In external rhinoplasty, the soft tissues of the nose may have additional swelling making minute changes of the dorsum difficult. When utilizing endonasal techniques it is crucial to expose the anterior septal angle to ensure that the supratip break can be manipulated and visualized.
Narrowing the open roof deformity:
The osteotomy site is injected with local anesthesia 5 minutes prior to allow for further vasoconstriction. A sharp soft tissue gouge is used to allow a passage lateral to the nasal bone for the osteotome and elevate the nasal periosteum. Osteotomies are performed with a guarded osteotome in a low to low manner. Osteotomies take place along the widest portion of the nasal bone in order to prevent a palpable and/or visual stepoff and create a natural contour to the nose. Incomplete osteotomies can be completed with a Quisling osteotome. After the osteotomies have been performed, the nose is evaluated. Ice is placed intraoperatively to allow for natural vasoconstriction intraoperatively.
You can also choose a rhinoplasty without osteotomy which is a less invasive nasal surgery that can address issues such as a dorsal hump or minor asymmetries, and typically requires shorter recovery time than traditional rhinoplasty.
Placement of Spreader Grafts:
Spreader grafts are placed into precise mucosal pockets if there is anticipated potential weakness of the middle third of the nose. The grafts are best fashioned from the septal cartilage along the nasal floor, just along the vomer. This portion of the septal cartilage is the strongest. Spreader grafts are placed by inserting the grafts in a precise pocket 2 mm from the dorsal aspect of the septum. Preservation of the dorsal mucosal cuff prevents the grafts from pushing out dorsally. The grafts are secured with a 3-0 chromic suture. If there is a mild septal deviation, asymmetric spreader grafts can be placed. (3) Typically, a larger spreader graft is placed on the side of the dorsal septal deflection, in order to push the nasoseptal pyramid over to the non-deviated side.
Closure of the incisions:
The mucosal incisions must be meticulously closed in order to prevent synechiae and potential alar retraction or notching. Preservation of vestibular mucosa allows for a natural and physiologic nose. A thin sheet of compressed gelfoam is placed along the dorusm to allow for even skin healing.
At the conclusion of the case, some patients may have excessive cartilaginous memory to the lower lateral cartilages. Vertical incisions are made with a 15 blade to score the cartilage, weakening the lower lateral cartilage while still preserving its overall natural contour. Vertical scoring is preferred because it reduces the spring of the lower lateral cartilages, allowing for convex cartilage shapes to become flatter over time. An important technical point with vertical cartilage scoring is symmetry in location and depth of the scoring to allow for gradual symmetric reduction in the bulbosity of the nasal tip.
A small sheet of paper is placed against the dorsal surface of the nose in an effort to protect it from contact from the glue from the paper tape or steristrips. Benzoin or topical glues are avoided to prevent skin sloughing, swelling, and minimize breakouts to the nasal skin. Aquaplast is contoured to support the nasal bones and maintain their position for one week postoperative. Ice is applied for 48 hours and beyond after the procedure continuously.
A variety of techniques can be classified under the broad term of cartilage splitting endonasal rhinoplasty with pros and cons associated with each technique. The classic transcartilaginous approach creates a bipedicled flap based on an incisions along the rim and a narrow blood supply. In the direct transcartilaginous approach, one incision is made along the vestibular skin and cartilage. Some authors have reported using percutaneous punctures to improve the accurate reshaping of the intermediate crus.(4) The authors (RK, ARS) report that visualization and palpation contribute to the ability to accurately assess the intermediate lateral crus region.
As many trends in rhinoplasty seem to come and go, the truest tests of any technique is time, predictability, and results. Open rhinoplasty and other techniques play a significant role and will continue to do so in rhinoplasty. Unfortunately, many surgeons are “overtreating” many patients who present for primary rhinoplasty surgery. Patients are being exposed to a litany of grafts and prolonged recovery periods. It is important for novice surgeons to realize that a longer surgery or more invasive surgery does not necessarily mean improved results and does expose the patients to far more complications.
Endonasal rhinoplasty is a technique quickly becoming a loss art in the fields of facial plastic surgery and plastic surgery. A recent survey found that 50% of surgeons are now using the open approach more than 50% of the time. (5, 6) While every rhinoplasty technique may have merit in specific situations, many surgeons are now aggressively treating primary rhinoplasty patients as revision cases, with multiple extraneous cartilage grafts . Unfortunately, as a result of overaggressive rhinoplasty, patients are suffering from unnatural outcomes, prolonged healing and recovery, and obvious stigmata of rhinoplasty.
Transcartilagious technique is a versatile primary rhinoplasty technique. It has the advantage of preservation of lower lateral cartilage shape and form, natural features of the nose, and maintains the anatomic integrity of the nose.
Raj Kanodia comment:
As the field of facial plastic surgery advances, new techniques and trends are often welcomed with unbridled enthusiasm despite limited follow up and experience. The field of rhinoplasty is no different. Many new purported advances have been mentioned such as alloplastic implants, autologous and homongenous grafts, alloderm, permacol, etc. However, the truest measure of a technique is consistent and durable results in which the nose looks natural.
While each rhinoplasty surgeon has a philosophy and artistic aesthetic unique to him, I have focused on emphasis of the existing beauty of the nose, rather than trying to completely change the character of the nose. One of the central tenants to my approach to rhinoplasty is to preserve and enhance the existing nose. The character of the nose, the natural features of the nose, the underlying structural integrity are all vital features which must be left undisturbed. Many of my patients have results which are so natural that it may virtually impossible to tell if they patient have had a rhinoplasty. I make changes in rotation, projection, deprojection by a combination of several techniques without damaging the integrity of the lower lateral cartilages. Primary noses only need refinement and finesse, not a changed rebuilt nose.
Many surgeons try to impose their vision of what is beautiful and in effect take away natural features of the face. Alar grafts, batten grafts, radix grafts may have a place in secondary rhinoplasty, but in primary noses, they bulk up the nose. Furthermore, most grafts add a certain rigidity to the nose taking away its natural feel and look. Although they may be able to achieve the desired amount of projection or deprojection, they do so at the expense of the rest of the nose. I believe that collective little changes can add up to a greater good, preserve natural beauty.
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