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Augmentation Rhinoplasty in Plastic Surgery Treatment & Management

  • Author: Luis Humberto Macias, MD; Chief Editor: Mark S Granick, MD, FACS  more...
 
Updated: Nov 19, 2012
 

Intraoperative Details

Surgical techniques may vary based on the surgeon's preference or experience. Numerous surgical technical descriptions are available in the rhinoplasty literature. Ortiz Monasterio and Michelena review several techniques for nasal dorsal augmentation.[17] Decongestion of the nasal mucosa with oxymetazoline, phenylephrine, or cocaine-soaked pledgets allows adequate endonasal visualization. Injection of the nasal soft tissues with lidocaine and epinephrine allows adequate vasoconstriction and decreases intraoperative bleeding.

Augmentation can be performed via an endonasal or an open rhinoplasty approach. The approach used depends on the complexity of the augmentation and the surgeon's preference. The endonasal approach requires an intercartilaginous, transcartilaginous, or intracartilaginous incision. In addition, a hemitransfixion or complete transfixion incision may be needed. An open approach involves elevation of the skin and soft tissue envelope via a transcolumellar incision that is carried along the medial crura and the caudal aspect of the lower lateral cartilages. The entire cartilaginous skeleton of the lower and upper lateral cartilages should be exposed.

Dissection should proceed in a submuscular aponeurotic plane. Dissection superficial to this plane results in compromise of the vascular supply to the soft tissues and makes the dissection very difficult. At the bony cartilaginous junction, the periosteum over the nasal bones is elevated and the dissection is carried in this plane up to the nasofrontal angle. The entire nasal skeleton should be adequately visualized. If a septoplasty is required for septal cartilage harvest or for correction of a septal deviation, the mucoperichondrium and the mucoperiosteum over the nasal septum is elevated from above via the open technique or through a hemitransfixion or complete transfixion incision via an endonasal approach.

Once the anatomy and the defects are adequately visualized, any further cartilage or bone harvest is performed. This may involve harvesting ear or rib cartilage.

The two most frequent areas for augmentation are the nasal tip and the nasal dorsum. Grafts are fashioned and sculpted to the desired size and shape and are sutured in the desired location. The graft is secured in place with carefully placed, multiple 5-0 clear nylon or polydioxanone sutures. Corrections are performed until the desired outcome is achieved. After augmentation is complete, incisions are closed endonasally with absorbable sutures. In the open technique, the skin and soft tissue envelope are carefully redraped over the nasal skeleton and sutured in place with 6-0 nylon, Prolene, or other absorbable sutures. Septal splints may be needed if septal cartilage was harvested. Any additional nasal packing may be performed based on the surgeon's preference. An external nasal splint may be needed if osteotomies were performed.

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Postoperative Details

Patients are educated on standard postoperative instructions. They are instructed to rest and sleep with the head of the bed elevated at 45 degrees for at least 72 hours after surgery. Any lifting, straining, or vigorous physical activity should be strictly prohibited for the first 4-6 weeks. Most preoperative medication can be resumed after consultation with the patient's primary care physician. Nasal mucosa should be kept moist with the use of saline sprays. Any sutures and splints should be removed in 5-7 days. If splints and packings are used, appropriate postoperative prophylactic antibiotics should be administered. Patients should be educated on the normal healing process and the time required for the edema to subside.

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Follow-up

Postoperative follow-up visits are generally scheduled for 1 week, 1 month, 3 months, and 1 year after surgery. Any revisions, if necessary, should not be performed before 12 months after the initial operation.

Rhinoplasty patients often require reassurance and patience. Good and open communication with the patient is mandatory during the recovery period.

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Complications

As is true in other surgical procedures, occasional postoperative complications should be expected in rhinoplasty. Fortunately, most complications are minor. In general, approximately 5-15% of patients require a revision rhinoplasty. Serious complications occur in less than 3% of patients and consist of postoperative bleeding, infection, implant or graft extrusion, recurrence of the problem, or anesthesia-related problems.

Endo et al reviewed 1200 cases of augmentation rhinoplasty using ear cartilage grafts and found that 4% of patients developed complications.[18] Graft malposition was the most common problem. Other problems that can occur include graft resorption, graft extrusion, malposition of the graft, or warping of the graft. These problems may take several years to become evident. Sheen reviewed his extensive experience with nasal tip grafts. In this 1993 series, he noted that graft malposition was the most common complication.[19]

If revisions are necessary, several options may be available to the rhinoplasty surgeon. Crushed cartilage, AlloDerm, and other nonautologous grafts can be used in revision rhinoplasty.

Although occasional complications cannot be avoided, they can certainly be minimized with appropriate patient selection, careful preoperative planning, meticulous intraoperative surgical technique, and good postoperative follow-up.

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Outcome and Prognosis

Rhinoplasty surgery has become more predictable over the years. As the understanding of the nasal anatomy and nasal/facial aesthetics has improved and the availability of augmentation materials has increased, the surgical outcomes have become more consistent and predictable. Rhinoplasty surgeons should thoroughly understand the anatomy, have an appreciation of facial and nasal aesthetics, accurately define the surgical problem, and adhere to meticulous surgical technique. Doing so ensures consistent results and minimizes complications.

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Future and Controversies

As new nonautologous materials become available, rhinoplasty surgeons will have more tools to augment and correct nasal deformities.

Han et al used cultured human fibroblasts suspended in Restylane as an injectable augmentation agent with satisfactory 1-year results.[20] Newer and longer-lasting filler agents like calcium hydroxylapatite (Radiesse) have emerged and are also being used to augment nasal contour deformities.

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Contributor Information and Disclosures
Author

Luis Humberto Macias, MD Fellow, Division of Plastic Surgery, University of Pennsylvania School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Dean Fardo, MD Private Practice, Atlanta

Dean Fardo, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

James E Zins, MD Chairman, Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation

James E Zins, MD is a member of the following medical societies: American Society of Plastic Surgeons, American Cleft Palate-Craniofacial Association, American Medical Association, American Society of Maxillofacial Surgeons, Ohio State Medical Association, Sigma Xi

Disclosure: Nothing to disclose.

Peter A Kreymerman, MD Plastic and Reconstructive Surgeon, Carolinas Center for Surgery, Carteret General Hospital

Disclosure: Nothing to disclose.

Heather Lucas MPAS, PA-C, Department of Surgery, Division of Plastic Surgery, Mayo Clinic Arizona

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

George Peck, MD 

George Peck, MD is a member of the following medical societies: American Society for Aesthetic Plastic Surgery

Disclosure: Nothing to disclose.

Chief Editor

Mark S Granick, MD, FACS Professor of Surgery, Chief, Division of Plastic Surgery, Rutgers New Jersey Medical School

Mark S Granick, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons, Phi Beta Kappa, Northeastern Society of Plastic Surgeons, New Jersey Society of Plastic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Waterjel, Inc.; Reconstat, LLC; DSM<br/>Serve(d) as a speaker or a member of a speakers bureau for: Novadaq<br/>Received none from Waterjel Inc. for board membership; Received none from Reconstat LLC for board membership; Received none from Open Science Co., LLC for board membership.

Additional Contributors

Frederick J Menick, MD Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona College of Medicine; Facial and Nasal Reconstructive Surgeon, Tucson, Arizona

Frederick J Menick, MD is a member of the following medical societies: American Society of Maxillofacial Surgeons, Canadian Society of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors C Coleman Brown, MD, Shashidhar Kusuma, MD, and Francis A Papay, MD to the development and writing of this article.

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Young boy with bilateral cleft lip and palate who also has midface hypoplasia and requires nasal augmentation.
Young boy (same patient as in previous image) with bilateral cleft lip and palate who also had midface hypoplasia and required nasal augmentation, shown after dorsal nasal augmentation was accomplished using autologous rib grafts. It was fashioned slightly larger than needed to account for the patient's future facial growth.
Woman with a subtype of midline granulomatous disease that caused nasal collapse. Augmentation was required.
Woman (same patient as in previous image) with a subtype of midline granulomatous disease that caused nasal collapse, shown after augmentation with both autologous rib and cartilage grafts. AlloDerm was also used for additional augmentation.
 
 
 
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