Augmentation Rhinoplasty in Plastic Surgery Treatment & Management
- Author: Luis Humberto Macias, MD; Chief Editor: Mark S Granick, MD, FACS more...
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. 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.
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.
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.
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. 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.
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.
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.
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. 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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