eMedicine Specialties > Plastic Surgery > Nose

Rhinoplasty, Augmentation: Treatment

Author: Peter A Kreymerman, MD, Clinical Fellow, Department of Surgery, Division of Plastic Surgery, Cleveland Clinic Foundation
Coauthor(s): Dean Fardo, MD, Associate Staff, Department of Plastic Surgery, Cleveland Clinic Foundation; James E Zins, MD, Chairman, Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation
Contributor Information and Disclosures

Updated: Jul 25, 2008

Treatment

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.9 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.

Postoperative Details

Patients are educated on standard postoperative instructions. Patients are instructed to rest and sleep with the head of the bed elevated at 30-40°. Any lifting, straining, or vigorous physical activity should be strictly prohibited. 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.

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.

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.10 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.11

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.

More on Rhinoplasty, Augmentation

Overview: Rhinoplasty, Augmentation
Workup: Rhinoplasty, Augmentation
Treatment: Rhinoplasty, Augmentation
Follow-up: Rhinoplasty, Augmentation
Multimedia: Rhinoplasty, Augmentation
References
[ CLOSE WINDOW ]

References

  1. Canady JW. Evaluation of nasal obstruction in rhinoplasty. Plast Reconstr Surg. Sep 1994;94(3):555-9. [Medline].

  2. Bottini DJ, Gentile P, Donfrancesco A, Fiumara L, Cervelli V. Augmentation Rhinoplasty with Autologous Grafts. Aesthetic Plast Surg. Oct 26 2007;[Medline].

  3. Stuzin JM, Kawamoto HK. Saddle nasal deformity. Clin Plast Surg. Jan 1988;15(1):83-93. [Medline].

  4. Powell NB, Riley RW. Facial contouring with outer-table calvarial bone. A 4-year experience. Arch Otolaryngol Head Neck Surg. Dec 1989;115(12):1454-8. [Medline].

  5. Godin MS, Waldman SR, Johnson CM Jr. Nasal augmentation using Gore-Tex. A 10-year experience. Arch Facial Plast Surg. Apr-Jun 1999;1(2):118-21; discussion 122. [Medline].

  6. Taylor CO, Owsley TG. Gore-Tex nasal augmentation. Plast Reconstr Surg. Jan 1996;97(1):252. [Medline].

  7. Rohrich RJ, Muzaffar AR. The Turkish Delight: A Pliable Graft for Rhinoplasty. Plast Reconstr Surg. May 2000;105(6):2242-2243. [Medline].

  8. Tosun Z, Karabekmez FE, Keskin M, Duymaz A, Savaci N. Allogenous Cartilage Graft Versus Autogenous Cartilage Graft in Augmentation Rhinoplasty: A Decade of Clinical Experience. Aesthetic Plast Surg. Oct 30 2007;[Medline].

  9. Ortiz Monasterio F, Michelena J. The use of augmentation rhinoplasty techniques for the correction of the non-caucasian nose. Clin Plast Surg. Jan 1988;15(1):57-72. [Medline].

  10. Endo T, Nakayama Y, Ito Y. Augmentation rhinoplasty: observations on 1200 cases. Plast Reconstr Surg. Jan 1991;87(1):54-9. [Medline].

  11. Sheen JH. Tip graft: a 20-year retrospective. Plast Reconstr Surg. Jan 1993;91(1):48-63. [Medline].

  12. Han SK, Shin SH, Kang HJ, Kim WK. Augmentation rhinoplasty using injectable tissue-engineered soft tissue: a pilot study. Ann Plast Surg. Mar 2006;56(3):251-5. [Medline].

  13. Adams WP Jr, Rohrich RJ, Gunter JP, et al. The rate of warping in irradiated and nonirradiated homograft rib cartilage: a controlled comparison and clinical implications. Plast Reconstr Surg. Jan 1999;103(1):265-70. [Medline].

  14. Constantian MB. Distant effects of dorsal and tip grafting in rhinoplasty. Plast Reconstr Surg. Sep 1992;90(3):405-18; discussion 419-20. [Medline].

  15. Eisenberg I. A history of rhinoplasty. S Afr Med J. Aug 21 1982;62(9):286-92. [Medline].

  16. Gilmore J. Use of Vicryl mesh in prevention of postrhinoplasty dorsal irregularities. Ann Plast Surg. Feb 1989;22(2):105-7. [Medline].

  17. Gryskiewicz JM, Rohrich RJ, Reagan BJ. The use of alloderm for the correction of nasal contour deformities. Plast Reconstr Surg. Feb 2001;107(2):561-70; discussion 571. [Medline].

  18. Guerrerosantos J. Augmentation rhinoplasty with dermal graft. Plast Reconstr Surg. Mar 2004;113(3):1080-1. [Medline].

  19. Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg. Apr 1997;99(4):943-52; discussion 953-5. [Medline].

  20. Hamra ST. Crushed cartilage grafts over alar dome reduction in open rhinoplasty. Plast Reconstr Surg. Feb 2000;105(2):792-5. [Medline].

  21. Peck GC Jr, Michelson L, Segal J, Peck GC Sr. An 18-year experience with the umbrella graft in rhinoplasty. Plast Reconstr Surg. Nov 1998;102(6):2158-65; discussion 2166-8. [Medline].

  22. Rogers BO. Early historic development of corrective rhinoplasty. In: Millard DR, ed. Symposium on Corrective Rhinoplasty. St. Louis, Mo: CV Mosby; 1976.

  23. Safian J. Corrective Rhinoplasty Surgery. New York, NY: Paul B. Hoeber, Inc; 1935.

  24. Sheen JH. The ideal dorsal graft: a continuing quest. Plast Reconstr Surg. Dec 1998;102(7):2490-3. [Medline].

  25. Stucker FJ, Hoasjoe DK. Nasal reconstruction with conchal cartilage. Correcting valve and lateral nasal collapse. Arch Otolaryngol Head Neck Surg. Jun 1994;120(6):653-8. [Medline].

  26. Stupak HD, Moulthrop TH, Wheatley P, Tauman AV, Johnson CM Jr. Calcium hydroxylapatite gel (Radiesse) injection for the correction of postrhinoplasty contour deficiencies and asymmetries. Arch Facial Plast Surg. Mar-Apr 2007;9(2):130-6. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

rhinoplasty, nasal augmentation, nose augmentation, nasal surgery, nose surgery, nose job, nasal plastic surgery, nasal deformity, revision rhinoplasty, nasal revision, secondary rhinoplasty, primary rhinoplasty

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Peter A Kreymerman, MD, Clinical Fellow, Department of Surgery, Division of Plastic Surgery, Cleveland Clinic Foundation
Disclosure: Nothing to disclose.

Coauthor(s)

Dean Fardo, MD, Associate Staff, Department of Plastic Surgery, Cleveland Clinic Foundation
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 Association of Plastic Surgeons, American Cleft Palate/Craniofacial Association, American Medical Association, American Society of Maxillofacial Surgeons, Ohio State Medical Association, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Frederick J Menick, MD, Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona College of Medicine; Private Practice in Tucson, Arizona
Frederick J Menick, MD is a member of the following medical societies: American Association of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic and Reconstructive Surgery, American Society of Plastic Surgeons, and Canadian Society of Plastic Surgeons
Disclosure: none None None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

George Peck, Jr, MD, Consulting Staff, Department of Plastic Surgery, St Barnabas Hospital of New Jersey
George Peck, Jr, MD is a member of the following medical societies: American Society for Aesthetic Plastic Surgery
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Deepak Narayan, MD, FRCS, Associate Professor of Surgery (Plastic), Yale University School of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center
Deepak Narayan, MD, FRCS is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Medical Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Indian Medical Association, Plastic Surgery Research Council, Royal College of Surgeons of Edinburgh, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.