Basic Closed Rhinoplasty

Rhinoplasty describes an array of operative techniques that can be used to alter the aesthetic and functional properties of the nose.[1] Surgical access to the nose can be gained via incisions placed inside the nose (endonasal approaches) or via incisions placed inside the nose combined with incisions placed outside the nostrils (external approach), usually on the columella. Prior to the increased popularity of the external (open) rhinoplasty approach in the last decade, the terms rhinoplasty and endonasal rhinoplasty were almost synonymous. This somewhat artificial division between external (open) and endonasal (closed) rhinoplasty has become an established part of current rhinoplasty nomenclature. Despite this, both approaches share many of the same incisions, and many of the same principles apply regardless of the approach chosen.

Proponents of endonasal rhinoplasty emphasize the following advantages:

• Decreased need for surgical dissection

• Decreased potential for nasal tip support reduction

• Reduced postoperative edema

• Corresponding decrease in the potential for overall scarring or iatrogenic insult to the nose

• Ability to make exacting changes in situ

• Via tactile palpation, a more immediate and predictable ability to feel changes made to the nose

• Ability to make targeted improvements without taking the nose apart

• Shorter operative times

• Theoretical reduction in morbidity, especially in older patients

• Elimination of any risk (however minimal) for developing a visible external columellar scar

• Reduced postoperative edema

• Quicker return to a normal appearance

The experienced rhinoplasty surgeon can use either an endonasal or an external rhinoplasty approach, based on the patient's rhinoplasty indications.[2] This article is a basic review of endonasal rhinoplasty techniques and concepts. The reader is encouraged to read the many high-yield articles and books listed in the references.

The history of nasal surgery is indeed long. The Edwin Smith surgical papyrus from ancient Egypt outlines the diagnosis and treatment of nasal deformities some 30 centuries ago.[3] In approximately 800 BCE, Sushruta, of India, described a nasal reconstruction approach based on the transfer of a pedicled forehead skin flap.[4] In the 16th century, Tagliacozzi of Bologna, Italy, used brachial-based delayed flaps to reconstruct noses. The science and art of rhinoplasty remained essentially stagnant until the 19th century. Approaches to correcting nasal deformities were used by early plastic surgery pioneers such as Dieffenbach in the 1840s, who used a buried forehead flap to cover the nasal dorsum.[5]

The first published account of a modern endonasal rhinoplasty can be traced to an American otolaryngologist, John Orlando Roe. His original article published 1887 was titled "The deformity termed 'pug-nose' and its correction, by a simple operation" and described the treatment of saddle nose deformities.[6] In 1892, Robert F. Weir, another American surgeon, also published his techniques for correcting the saddled nose.[7]

In 1898, Jacques Joseph, an orthopedic surgeon by training, presented his revolutionary concepts of nasal surgery to the Medical Society of Berlin. Many aspiring rhinoplasty surgeons traveled to Germany to watch Joseph perform his rhinoplasties. His general reputation as the father of modern rhinoplasty can be supported by his influence in shaping many rhinoplasty concepts and techniques. In fact, many of the basic rhinoplasty maneuvers remain essentially the same today as when Joseph first described them. Joseph's concepts and techniques were further disseminated (especially in the United States) by surgeons such as Gustav Aufricht, Joseph Safian, and Samuel Fomon. Fomon's teachings and medical review courses on endonasal rhinoplasty helped in the education of countless early modern rhinoplasty surgeons, such as Maurice Cottle of Chicago and Irving Goldman of New York.

In the relatively short history of modern rhinoplasty, many additional rhinoplasty masters have contributed to the advancement of the field. Countless surgeons continue to advance our understanding of the art and science of rhinoplasty through their scholarly and clinical works. The continued sharing and dissemination of rhinoplasty knowledge has hopefully benefited the patient and surgeon alike.

Most patients seek rhinoplasty surgery to improve the aesthetic features of the nose. Others may elect to have a rhinoplasty for functional improvement of the nasal airway. Most often, both cosmetic and functional issues are addressed during rhinoplasty.

Etiologies of nasal deformity can be (1) hereditary/familial (eg, large dorsal hump), (2) traumatic (eg, after a motor vehicle accident), (3) iatrogenic (eg, unfavorable result from previous rhinoplasty), or (4) congenital (eg, cleft palate nasal deformity).

Septal deviation, inferior turbinate hypertrophy, deviated nasal bones, and narrow internal nasal valve area can all negatively impact the nasal airway. These issues must be addressed during rhinoplasty surgery.

Indications include (1) aesthetic deformity, (2) patient request for a change in nasal shape, and (3) improvement of anatomic nasal airway obstruction.

A great majority of rhinoplasties performed are purely elective in nature. As such, the surgeon must exercise judgment in selecting patients who want to have this type of surgery. This judgment is guided by surgical principles, the patient's psychologic state, and the ethical consideration of minimizing any iatrogenic harm to otherwise healthy patients. A brief list of common contraindications includes the following:

• Unstable mental status (eg, unstable patient with schizophrenia)

• Unrealistic patient expectations

• Previous rhinoplasty within the last 9-12 months (applies only to major rhinoplasties)

• Poor perioperative risk profile

• History of too many previous rhinoplasties, resulting in an atrophic skin–soft tissue envelope and significant scarring

• Nasal cocaine users

Photography

Standardized photographs of the patient are essential to the preoperative diagnosis and for the development of a mental surgical plan. Capturing high-quality patient photographs can be accomplished using 35-mm film or digital photography techniques, which are described in detail in other sources. Preoperative analysis of patient photographs allows the surgeon to define problem areas of the nose that may have been missed during the initial physical examination. Also, specific structural and anatomic deficits may become more apparent in certain photographic views.

A review of patient photographs the night before surgery can also serve to refresh the surgeon's memory, help anticipate likely intraoperative anatomy, and allow the surgeon to rehearse the projected operative plan. Photographs are also valuable in objectively revealing preoperative and postoperative findings. Such documentation is also helpful in critical self-analysis of techniques and long-term results.

Certain minor nasal contour deformities can be "filled in" with temporary nonreactive dermal fillers like Restylane. In rare cases, the author has used non-animal stabilized hyaluronic acid gel (Restylane, Q-MED, Upsalla, Sweden) to correct minor nasal contour deformities in patients who do not want to have surgery. The author uses only Restylane, because it is temporary, it is minimally tissue-reactive, and, if necessary, it can be reversed with hyaluronidase injections.

Preoperative evaluation

In general, nasal analysis can be divided into 4 basic components addressing the different areas of the nose. The first is the lower third of the nose (nasal tip and base), the second is the middle third of the nose (middle vault), the third is the upper third of the nose (bony vault), and the fourth is the septum. The typical first steps in a successful rhinoplasty are (1) a careful preoperative analysis of the patient's concerns and nasal deformities and (2) the generation of a problem list. Accurate preoperative diagnosis of both aesthetic and functional problems can then facilitate appropriately targeted rhinoplasty maneuvers.

After a routine (but important) medical history interview and physical examination, the surgeon's focus is directed to the face and nose. The patient evaluation begins with listening to the patient's main concerns and requests. Despite the fact that most patients seek to undergo rhinoplasty for aesthetic reasons, the functional role of the nose must be kept in mind.

Questions about nasal function are paramount, especially in many patients who may have previously undiagnosed functional nasal problems. Most rhinoplasty procedures tend to narrow the nasal airway. As such, a patient with a preoperatively borderline-normal nasal airway may experience postoperative nasal breathing problems. By recognizing functional issues preoperatively, many patients' nasal airways may be improved by nasal surgery. The physician has the responsibility to diagnose and educate the patient about any existing functional deficits. No amount of aesthetic gain is worth crippling the function of the nose. Finally, as with any plastic surgery procedure, the patient's psychological stability, ability to understand the risks and benefits of the proposed procedure, and sense of body self-image must be evaluated.

Aesthetic goals in rhinoplasty are shaped by the patient's requests, the patient's nasal anatomy, and the surgeon's recommendations based on aesthetic ideals. A complete discussion of facial aesthetics is beyond the scope of this article, but a number of salient points are highlighted. Aesthetic ideals and proportional norms of the human face and nose have been well studied and documented by artists, behavioral scientists, and physicians. These aesthetic norms have validity in most white patients, but they may not be as useful in patients of other races. (For information about rhinoplasty in patients of Asian descent, please see Medscape Reference article Asian Rhinoplasty.) Ideal anthropometric values for a number of facial angles and ratios can serve as a useful guide. Ideal facial and nasal angles are as follows:

• Nasofrontal angle - 115-130°

• Nasofacial angle - 36° (30-40°)

• Nasolabial angle - 90-105° (males), 100-120° (females)

A surgeon's ideal rhinoplasty outcome may not always be congruent with the patient's desires. The surgeon should discuss the rhinoplasty plan and his or her recommendations with the patient during the preoperative consultation. The surgeon should proceed further only when a clear, mutual understanding of the rhinoplasty goals has been achieved. The end product of a well-executed rhinoplasty includes (1) bilateral symmetry, (2) an unbroken brow-tip aesthetic line, (3) a straight nasal contour on frontal view, (4) adequate nasal sidewall shadowing, (5) a smooth dorsal profile, and (6) a nose that is in harmony with the rest of the face.

On frontal view, an attractive nasal tip demonstrates well-defined and symmetric tip-defining points (domal highlights), minimal-to-no bulbosity, minimal-to-no infratip dependency, symmetric alar rims, and appropriate nasal base width. On lateral view, the nose should be adequately projected and the nasal tip should lead the nasal dorsal profile by 1-2 mm, creating a favorable supratip break. For more information, see Medscape Reference article Tip Rhinoplasty.

The nasal staring point (radix) should be at the level of the upper eyelid crease. A high dorsal profile is preferred in most patients. The rotation of the nose and nasolabial angle can vary depending on the patient's facial features, height, and sex. On the lateral view, the columella should lead the alar rim by 2-3 mm (defined as columellar show). The projection of the chin should also be evaluated from the lateral view. A retrusive chin may require augmentation to bring it in balance with the nose. On base view, the width of the base (ie, the distance between the lateral aspects of the ala) should correspond to the approximate width of the intercanthal distance. This may be wider in patients with nasal features that are common among people of Asian and African descent.

Physical examination

Anatomic analysis of the nose relates to both the aesthetic and functional properties of the nose. For instance, a patient's concern about unilateral nasal obstruction may be the result of nasal septal deviation. Often overlooked are the posterior (osseus) septal deviations, septal spurs on the nasal floor, or enlarged turbinates due to allergies. If rhinologic allergies are suggested, an empiric treatment trial with a nasal steroid for 4-6 continuous weeks may be considered prior to reevaluation for any possible turbinate surgery as part of the rhinoplasty. For more treatment information, see Medscape Reference article Allergic Rhinitis.

In the absence of significant nasoseptal deviation, a patient's concern about bilateral nasal obstruction may be an indication of external valve collapse due to a flail ala. In such cases, supporting the lateral aspect of the nostril with a nasal speculum should improve subjective nasal airflow. Flail alae are commonly seen in elderly patients and in some patients with cephalically positioned lower lateral cartilages.

An incompetent internal nasal valve can also create significant nasal obstruction. Patients with a narrow middle vault, a history of previous rhinoplasty, or shorter nasal bones are at higher risk for internal nasal valve problems. A useful clinical test for diagnosing internal nasal valve incompetence can be performed using the Cottle maneuver. This involves assessing subjective nasal breathing status before and after the forced lateral displacement of the medial aspect of the cheeks. Improved nasal airflow with the Cottle maneuver is highly suggestive of internal nasal valve incompetence. False-positive results with the Cottle maneuver can also occur with alar collapse.

Palpation of the nasal bones can help determine their size and contribution to the contour of the dorsum. Nasal humps are usually osseocartilaginous with a greater cartilaginous component. The integrity of nasal tip structures and overall support mechanisms can be partially deduced from the amount of nasal tip recoil present after pressing against the tip. With a gloved finger, bimanual intranasal examination can help determine the orientation of caudal septal cartilage, the thickness of the membranous septum, and the size of the nasal spine. Palpation can also help determine the thickness of the nasal skin soft tissue envelope.

Anesthesia

Anesthesia for the rhinoplasty patient depends on the surgeon's preferences. Deep intravenous (propofol) sedation, monitored anesthesia care, and general anesthesia have different risks and benefits. With any method, depositing local anesthetic with diluted epinephrine (1% lidocaine with 1:100,000 epinephrine) can help ensure desired vasoconstriction, hydrodissection, and local anesthesia.

Depositing just enough local anesthetic to achieve the desired pharmacological effect while minimizing tissue distortion is important. Depositing local anesthetic in proper locations and into avascular areolar tissue planes is key. This can decrease bleeding, facilitate tissue dissection, reduce surgical trauma, and ease execution of the surgical plan. The use of intranasal pledgets soaked with a vasoconstrictive agent (eg, 4% cocaine solution, oxymetazoline) can facilitate endonasal decongestion, decrease intranasal bleeding, and provide additional local analgesia (ie, if cocaine is used).

Endonasal rhinoplasty approaches and incisions

The endonasal approaches can be divided into the 2 broad categories of nondelivery approaches and delivery approaches. The nasal cartilages can be exposed for adequate surgical access through numerous incisions (see images below) or a combination of incisions placed in the nose and on the septum.

Approaches and associated endonasal incisions are as follows:

• Nondelivery approach

  • Cartilage splitting - Transcartilaginous incision

  • Retrograde or cartilage inversion method - Intercartilaginous incision

• Delivery approach

  • Bipedicled chondrocutaneous flap (ie, dome delivery method) - Combination of alar marginal and intercartilaginous incisions

  • Lateral crus delivery - Alar marginal incisions

Septal incisions (see image below) include the Killian incision, hemitransfixion incision, and full-transfixion incision.

The surgical approach to the nose should be chosen based on the amount of nasal tip work anticipated. In general, minor tip deformities (eg, slight bulbosity, minor tip rotation, minor supratip break enhancement) can be addressed by a nondelivery approach using a transcartilaginous (cartilage-splitting) incision. Moderate nasal deformities (eg, moderate bulbosity, moderate tip rotation, small grafts) can be addressed using either a nondelivery or delivery approach. The delivery approach using a bipedicled chondrocutaneous flap is well suited for more complicated cases such as noses with moderate-to-major deformities, the need for tip narrowing techniques, structural grafting, correction of significant asymmetry, or revision cases.

Rhinoplasty techniques

The flow of operative maneuvers in rhinoplasty should be deliberate, supported by logic, and based on the surgeon's practical experience. Using a problem-oriented approach, some advocate addressing the area of greatest concern or deformity first, followed by other areas of the nose. For instance, in a classic reductive rhinoplasty, the surgeon may first reduce the nasal hump and then perform the needed nasal tip work. In general, the authors usually prefer to start the operation by setting the desired nasal tip projection and rotation first and then addressing the middle and bony vaults last. If indicated, the authors perform a septoplasty first, to either correct septal deviations or harvest graft material. If a significant nasal hump reduction is planned, the authors delay the septoplasty until all hump removal is accomplished. This helps prevent inadvertent overresection of dorsocolumellar septal cartilage.

Septal work

Septal incisions (see image below) can be used in performing septoplasty, for harvesting cartilage, and for facilitating other corrective maneuvers in the septum.

Deviations in the cartilaginous and bony components of the nasal septum can contribute to nasal obstruction. Septal deviations and fractures can also significantly contribute to the crooked nose deformity, especially after facial trauma. Both C- and S-shaped nasal deformities usually reflect the orientation of the septum in the middle and lower thirds of the nose. In such cases, straightening the nasal bones without adequately addressing the septum leaves most patients with residual nasal deviation. In cases in which the septum has been subluxed, a swing-door maneuver can be used to medialize, and then suture-fixate, the septum to the maxilla. A transfixion or Killian septal incision may be used when performing septoplasty (see image below).

Septal injections with local anesthetic (1% lidocaine with 1:100,000 epinephrine) can be used for anesthesia, hydrodissection, and hemostasis. Robust subperichondrial flaps are raised in a naturally occurring bloodless plane, exposing septal cartilage and bone. Deviated cartilage is taken out, crushed, straightened, and placed back in the nose. Excised cartilage also may be used later for grafting purposes. Bony deviations are generally carefully excised and not replaced. To ensure proper support and to prevent postoperative saddling, a generous (>15-mm) dorsocolumellar cartilaginous strut is left behind for adequate support (see image below). The mucoperichondrial flaps are then approximated together with a running (4-0 chromic) stitch.

The caudal septum can contribute to a number of aesthetic deformities. Using a hemitransfixion or full-transfixion incision, the caudal septum and membranous septum can be accessed for surgical excision or placement of grafts. Excision of an overly long septum can be used to shorten the nose. Conservative thin-wedge resection of the caudal septum can be used to decrease columellar show and to shorten the nose. Resection at the area of the anterior septal angle can contribute to a slight increase in tip rotation and a decrease in tip projection. A triangular-wedge excision at the posterior septal angle can decrease nasolabial fullness and webbing.

A full-transfixion incision can detach the columella, the medial crura of alar cartilages, and the membranous septum from their attachments to the caudal cartilaginous septum. With a full-transfixion incision, several tip support mechanisms (see below) are violated. This can be used favorably to decrease the nasal tip projection in larger noses. Using the transfixion incision, cartilage grafts can be placed in the columella for augmentation or additional tip support.

Major and minor nasal tip support mechanisms are as follows:

• Major

  • Size, shape, and resilience of the alar cartilages

  • Attachment of the medial crural footplates to the caudal membranous and cartilaginous septum

  • Attachment of the lower lateral (alar) cartilages to the upper lateral cartilages

• Minor

  • Interdomal condensations and fibrous attachments

  • Lateral alar attachments (including the sesamoid cartilages)

  • Cartilaginous septal dorsum

  • Nasal spine

  • Membranous septum

  • Skin and soft tissue attachments to the alar cartilages

A study by Scattolin et al indicated that revision rhinoplasty with an endonasal septal extension graft is an effective means of correcting a short nose resulting from overresection of the caudal septum. The report involved 38 patients who, following initial rhinoplasty, had a hypoprojected and hyperrotated nasal tip. The closed revision procedure increased nasal length by 15.02% and augmented tip projection by 11.34%, with decreases occurring in the columellar-labial and -lobular angles. The investigators reported no relevant postoperative complications.[8]

According to a study by Harel et al, changes to septal extension graft procedures in endonasal rhinoplasty have made the grafts more reliable, with benefits seen in tip projection and rotation. In study patients who underwent the grafts, the mean preoperative nasolabial angle was determined to be 93.75°, while the mean postoperative angle was 101.1°, with the standard deviations, at 9.45° and 5.3°, respectively, revealing a narrower range for the angle following surgery. Moreover, the preoperative and postoperative Crumley ratios were 3.84 and 4.04, respectively, indicating that the nasal proportions had changed significantly.[9]

Basic tip-sculpting techniques

The lower lateral cartilages provide much of the structural support responsible for the external shape of the nasal tip. Nasal tip support mechanisms (one of which includes the strength of the alar cartilages) must be strong enough to support the postrhinoplasty redraping of the soft tissue skin envelope and to withstand the long-term contractile forces produced by scarring. Major and minor tip support mechanisms (see above) may be interrupted in rhinoplasty.

Based on such biomechanical principles and the cumulative lessons learned from almost a century of rhinoplasty knowledge, avoiding overresection of cartilaginous structures of the nose remains crucial. The emphasis in rhinoplasty should be on preservation, reorientation, and reshaping of cartilages as much as possible, minimizing cartilage resection to only what is absolutely necessary.

When using a nondelivery approach, the alar cartilages must be carefully palpated and outlined to avoid inaccurate cartilage resection. The back of a surgical knife handle or tip of the suction device can be used to feel for a step-off in the vestibular skin, which defines the borders of cartilage-bearing areas (see images below). In thin-skinned patients, the cutaneous outline of the cartilages can also be helpful in predicting the boundaries of the alar cartilages and corresponding endonasal incisions. When planning endonasal incisions, caution must be exercised in patients with significant alar cartilage asymmetry, cephalic lateral crural positioning, previous rhinoplasty, and very thin alar cartilages. In these cases, surgeons must be cognizant of such variant anatomy and must fashion their incisions more carefully according to the anatomy present.

Drawing anatomic landmarks can be helpful for reminding the surgeon of the relevant anatomy throughout the procedure (see image below). Each nasal tip–defining point and its corresponding endonasal location can be pinpointed by percutaneous insertion of a 27-gauge or thinner needle. A similar needle-guided technique can be used to match nasal surface topography with its endonasal anatomic counterpart. This technique can be quite useful in ensuring accuracy of incision placement. When viewing endonasal structures, using a sharp, double-pronged retractor in the nondominant hand to evert the caudal edge of the alar rim is helpful. The middle finger on the retracting, dominant hand can be used to press down on the cartilages. Light entry and maximal exposure is facilitated by eversion and retraction of the alar rim, along with simultaneous inferomedial displacement of the alar cartilages.

Cephalic trim

Cephalic resection (complete strip) of the lower lateral (alar) cartilages has been the traditional workhorse of nasal tip surgery (see image below). The maneuver can help reduce nasal bulbosity, contribute to creating a subtle supratip break, increase the pliability of the alar cartilages for other tip-defining maneuvers (eg, with dome suturing), and achieve small degrees of cephalic tip rotation. A point that must be emphasized is that at least 6-8 mm of alar cartilage must be preserved—more with weaker cartilages. Overresection of the alar cartilage can result in the long-term development of alar collapse, supratip pinching, bosses, asymmetries, and other undesirable results. Leaving sufficient cartilage behind helps minimize these long-term complications.

Cephalic resection can be performed via nondelivery and delivery approaches. When using the delivery approach, commonly found cartilaginous asymmetries can be readily appreciated. When excising cartilage, focusing on how much cartilage is left behind is helpful to ensure adequate symmetry. If perfectly symmetric bilateral excisions are performed on asymmetric alar cartilages, the resultant anatomy remains asymmetric.

Alar suturing techniques

Suture fixation can be used in a number of ways to change the shape of alar cartilages and the nasal tip with minimal resection. Suture fixation techniques require a delivery approach in which chondrocutaneous flaps are delivered outside the nose for surgical manipulation. Intradomal horizontal mattress sutures can be used to narrow the domal angle between the lateral and medial crura. When combined with a conservative cephalic trim, tip narrowing, cephalic rotation, and a slight (1-2 mm) increase in projection may be achieved.

Intradomal sutures can be placed on each dome independently in a manner to maximize symmetry of the newly created domal contours. Interdomal sutures are placed in between the alar domes. Interdomal cartilages can decrease the interdomal distance (decreasing bifidity), help set final symmetry between the paired domes, and add structural support to the nasal tip. The medial crura can also be suture-fixated to each other to achieve extra support, correct buckling, or align other medial crural asymmetries. Suture fixation can also be used to secure the alar cartilages to the caudal septum for additional support.

Nasal tip grafting

The use of cartilaginous autografts harvested from the septum or the auricle can be of great help to the rhinoplasty surgeon. Cartilage grafts can be used for augmentation, for camouflage, and to bolster the structural support of the nose.[10] Cartilage grafts can be placed via a nondelivery method by creating precise pockets for placement of requisite grafts. Alternatively, suture fixation of grafts or the placement of a larger graft may benefit from the access provided by the delivery method.

Shield-shaped cartilage grafts can be placed in the anterocaudal aspect of the nose. Such tip grafts can provide added projection, favorable supratip and infratip breaks (double-break), the illusion of increased nasal length, improved symmetry, and a more favorable tip contour. Various shapes of cartilage grafts can be placed into precise pockets to camouflage or augment as needed. Caution must be exercised in patients with thin skin because such grafting may show through the skin. In such cases, shaping and contouring the edges of the grafts can soften their visible outline through thin skin. Also, a layer of crushed (or morselized) cartilage, fascial grafts, or commercially available dermal allografts can be applied to cushion and soften the graft's outline through the skin.

A study by Zeng et al suggested that in East Asian patients, a bulbous, underprojected nasal tip with thick skin can effectively be corrected via closed rhinoplasty, using a mushroom-shaped costal cartilage graft. At mean 15.8-month postoperative follow-up, patients had a mean nasofrontal angle of 137.7°, a mean nasolabial angle of 94.1°, a mean nasal tip angle of 79.4°, and a mean columellar/lobular angle of 44.7°. The mean tip projection/nasal length and columellar/lobular length indexes were 0.53 and 1.21, respectively. No prolonged functional complications occurred.[11]

Almost every part of the nose can be modified with the placement of cartilage grafts. Columellar struts can augment the caudal projection of the columella (increasing columellar show), enhance support, and decrease the chances of long-term columellar retraction. Typically, columellar strut grafts are thin, rectangular cartilaginous grafts that can be placed in between or in front of the medial crura. Larger columellar grafts can be sutured to the caudal septum and can serve as caudal extension grafts.

Alar batten grafts are small, pear-shaped, oval cartilage grafts that can be placed just above or at the superior aspect of the alar sidewall. Alar battens can help reinforce the integrity of the alar sidewall, especially in cases of cephalically oriented alar cartilages, aging noses, or previously overresected lateral crura. Alar batten grafts can also help remedy aesthetic deformities such as supra-alar pinching. In some cases, thin slices of cartilage (ie, rim grafts) can be placed through rim incisions to support the caudal alar sidewall. Alar rim grafts can be used to add minimal support to the ala, provide added alar definition, and reduce the possibility of long-term alar retraction. Composite chondrocutaneous grafts from the auricles can also be used to treat greater degrees of alar retraction.

Nasal base surgery

The nasal base, as with the rest of the nose, contributes to the functional and aesthetic properties of the nose. Nasal base shape and nostril orientation norms vary considerably among different ethnic groups. When compared with the typical leptorrhine (white) nose, increasingly wider interalar distances are respectively found in the mesorrhine (Asian) and platyrrhine (African) noses. Achieving increased nasal base triangularity, symmetry, and minimization of alar flaring are desirable goals in rhinoplasty. The ideal interalar distance in the leptorrhine nose corresponds to the approximate intercanthal distance. This ideal norm should be wider in many Asian and African noses.

The degree of alar base widening and alar flaring can be influenced by many factors, including the orientation of the alar cartilages, the strength of the alar cartilages, the insertion angle of the ala onto the face, and nasal tip projection. Alar base resection is one way to narrow the base. It involves full-thickness excision of skin with its underlying soft tissue in the area of the nostril sill. A slightly more lateral placement of the excision into the insertion of the ala can also reduce excessive alar flare, in addition to narrowing the base (see image below).

As would be expected, alar base resections are indicated more frequently for wider noses. In a typical reductive rhinoplasty on a patient with a wide base, minimal lateral alar base excisions may be useful in reducing alar flaring and enhancing triangularity. Alar flaring may develop intraoperatively after nasal tip deprojection that results in displacement of excess alar tissue laterally (flaring). The risks of deleterious nostril narrowing and airway compromise should temper the routine use of alar base resection in all patients.

The imposition of the medial crura and their footplates into the nostrils can lead to an unattractively widened columellar base and, potentially, reduced airflow. Such widely divergent medial crural footplates can be brought together by suture fixation or, in very rare cases, by partial footplate amputations. Suture fixation of the medial footplates and medial crura can also be used to add support to the lower third of the nose.

Nasal dorsal alignment

The nasal dorsum is formed by a confluence of the ascending process of the maxilla, the nasal bones, the septum, and the upper lateral cartilages. The nasal starting point (ie, radix or nasion) is defined by the location of the nasofrontal junction and can influence the perceived length of the nose. The nasal bones, combined with middle vault, define the nasal dorsal height relative to the nasal tip. Skin is thickest in the tip, thinner in the nasofrontal area, and thinnest at the rhinion (ie, osseocartilaginous junction). The differential thickness of the nasal skin also contributes to the appearance of the nasal profile.

Dorsal convexities are common and should be reduced conservatively. Access to the nasal dorsum can be attained via previously placed intranasal incisions. The cephalad skin and soft tissue envelope can be elevated using a No. 15 blade or scissors over the middle vault perichondrium and bony vault periosteum. With the elevation completed, a nasal (Aufricht) retractor can be used to facilitate visualization.

Nasal hump reduction is begun with scalpel resection of the cartilaginous part of the nasal hump. Using a new, sterile No. 15 blade, the cartilaginous dorsum is lowered to the desired height (see image below). The anterior septal angle is reduced to below the level of the alar domes to create a favorable supratip break and to minimize a "polly beak" deformity. During this maneuver, the alar cartilages can be protected by pulling them caudally and inferiorly with the opposite hand.

The line of hump resection is developed with the knife, and then it is continued into the nasal bones using an (Rubin) osteotome. Only a small amount of bone should be removed because additional reduction can be achieved using appropriate rasps. Rasping with progressively finer rasps can be used to further smooth the dorsum. Alternatively, with smaller dorsal bony convexities, rasping alone may achieve the desired bony profile.

Intraoperatively, the exact contour of the nasal dorsum may be obscured by edema from the injection of local anesthetic, edema from surgical dissection, and the natural differential in skin thickness of the nasal dorsum from the radix to the tip. As such, a straight-line reduction of the nasal dorsum intraoperatively may lead to dorsal overresection that becomes apparent several months after the rhinoplasty. Periodic inspection and palpation of the profile can alert the surgeon to the presence of any dorsal irregularities. Further rasping or shaving with the knife can be used to smooth the dorsum. Leaving a higher dorsum is desirable to ensure a strong profile, especially in males and in patients at midlife and beyond. Leaving a slightly higher dorsum also lends a more natural, nonoperated look to the patient, in addition to providing the surgeon with an additional margin of safety.

Most nasal hump reductions result an intraoperative open roof deformity. An open roof deformity is formed when an osseocartilaginous hump is removed, exposing the unroofed nasal septum, upper lateral cartilages, and lateral nasal bones. This open roof can be closed using medial and lateral osteotomies (see Osteotomies) to reconstitute a continuous dorsal bony pyramid.

The middle vault occupies an important functional and aesthetic role in the nose. The internal nasal valve is found in the middle vault in the area where the upper lateral cartilages and septum meet.[12] The internal nasal valve represents the area of greatest resistance of nasal airflow. If its function is compromised, nasal obstruction can result.

Most dorsal convexities (humps) usually have a significant cartilaginous component. Any hump reduction may destabilize and compromise the attachment of the upper lateral cartilages, leading to internal valve incompetence. Postrhinoplasty nasal valve compromise may result from scarring, inferomedial displacement of the upper lateral cartilages, or resection of upper lateral cartilages. Unstable upper lateral cartilages can result in long-term aesthetic complications such as an inverted-V deformity, nasal sidewall asymmetries, middle vault narrowing, and even saddling.

Spreader grafts can be used to minimize or correct such problems. Spreader grafts can be placed through subperichondrial tunnels between the septum and the upper lateral cartilages. Properly placed spreader grafts serve to preserve or increase middle vault width, expand the cross-sectional area of the internal nasal valve, and decrease the risk of inferomedial collapse of the upper lateral cartilages.[13] A retrospective study by Samaha and Rassouli of endonasal spreader graft placement in closed rhinoplasty supported the view of the procedure as safe. The study involved 100 patients, three of whom demonstrated a cartilaginous dorsal spur due to the cephalic edge of the graft becoming visible, and one of whom developed an ecchymosis along the dorsum. The ecchymosis produced a hump, which resolved in 2 months. These were the only functional or aesthetic complications that occurred.[14] For more information, see Medscape Reference article Spreader Grafts Rhinoplasty.

In case of inadvertent overresection or palpable dorsal irregularities, onlay grafts (eg, cartilage, crushed cartilage, fascia, dermal allografts) can be used to augment the dorsum or to camouflage irregularities.

A study by Harel and Margulis indicated that, as in open rhinoplasty, diced cartilage wrapped in a sleeve of autologous fascia can be used for nasal dorsum reconstruction in endonasal rhinoplasty. The study involved 18 patients who underwent secondary endonasal rhinoplasty; a graft made from conchal, septal/conchal, or costal cartilage, enclosed in deep temporal fascia, was placed endonasally into the dorsum. During a minimum follow-up period of 15 months, three patients suffered complications, but just one needed surgical revision (to correct contour irregularity). No cartilage resorption occurred in any of the 18 patients.[15]

Osteotomies

Osteotomies are controlled fracture lines created by the surgeon to mobilize and reshape nasal bone segments into the form desired. Osteotomies can be divided into those designed to fracture the lateral nasal osseous pyramid (ie, lateral osteotomies) and those aimed at mobilizing the medial aspect of the nasal osseous dorsum (ie, medial osteotomies). For more information, see Medscape Reference article Osteotomy Rhinoplasty,.

Medial osteotomies are usually performed first. They are started from the vertical midline, then, at a 20° angle, they are obliquely curved toward (but not higher than) the medial canthus. If a sizable dorsal hump resection has been performed, then medial osteotomies may not be needed because the medial attachments of the nasal bones have already been interrupted.

Osteotomies on the lateral nose can be further divided into lateral and intermediate osteotomies. Lateral osteotomies, when combined with medial osteotomies, can be used to narrow the bony vault, correct bony asymmetry, enhance nasoorbital sidewall shadowing, and slightly increase nasal bony vault projection.

Intermediate osteotomies are placed higher than lateral osteotomies and are used to further mobilize the nasal bones, especially in cases of significant asymmetry. Intermediate osteotomies can also be performed to further narrow a wide bony pyramid. By convention, the position of lateral osteotomies (high vs low) is defined based on a supine patient in relation to the ceiling (see image below). Curvilinear lateral osteotomies are started at the pyriform aperture where a high-low-high osteotomy line is created up to the medial canthal line. Mucosal incisions and osteotomy site mucoperiosteal flap elevation are not required when a 3-mm or smaller osteotome is used.

Lateral osteotomies are initiated at the pyriform aperture or just above the attachment of the inferior turbinate to the ascending process of the maxilla in order to prevent inferior turbinate destabilization. Osteotomies should not extend more cephalad than the harder bones found at the approximate level of the medial canthi. Extending the osteotomies further cephalad than the medial canthal line does not yield much additional cosmetic benefit, but it does significantly increase the risk of a "rocker deformity."

The initiating fracture line of the lateral osteotomy should also be placed low enough to allow for a large lateral nasal wall infracture. This decreases the chance of creating a palpable step deformity, which can occur when lateral osteotomies are positioned too high. The newly osteotomized bones should be freely mobile upon manual palpation, but they should be splinted by the undisturbed periosteum and soft tissues that remain attached to the bony fragments.

The ultimate goal of combined medial and lateral osteotomies is to create a continuous fracture line so that the shape of the nasal pyramid can be reset to the surgeon's liking. Percutaneous osteotomies using a 2-mm osteotome through a small skin-stab incision can be used to complete osteotomies in areas not adequately fractured and mobilized.

Postoperative care for rhinoplasty patients should maximize patient comfort, reduce nasal swelling, and provide immobilization and stabilization of the nose. Immediately after the rhinoplasty, Steri-Strips or strips cut from surgical brown tape are applied to the nose to reduce edema, securely immobilize loose bone segments, and pad the nasal cast.

The surgeon can use a taping process to help influence favorable healing and scarring of the nose. Various nasal casts are commercially available. Ideally, the nasal cast to should cover most of the nose without impinging on the medial canthus or nasofacial junction. The nasal cast is usually left on for 5-6 days. The patient is instructed to not remove or touch the nasal cast and to keep it dry. Nasal taping and casting can also serve to allay the negative psychological impact of immediate postrhinoplasty bruising and edema on the patient. Some advocate an extended period of nasal taping for several weeks to influence favorable healing.[16]

Nasal packings and systemic antibiotics are not routinely used. If nasal packs are placed, oral antibiotics are started to reduce the risk of toxic shock syndrome. Nasal packs are removed prior to discharge and are almost never left in place for more than one day. Plastic or silicone intranasal splints are placed in patients who undergo septal work or those who may be at risk for developing intranasal synechiae. With an uncomplicated septoplasty, the intranasal splints are removed in 5-6 days.

Patients with intranasal splints are encouraged to use normal saline irrigations several times each day to cleanse the intranasal cavity. Intranasal application of topical antibiotic ointment using a cotton-tipped applicator may be recommended in the motivated and coordinated patient. Prior to surgery and once again prior to discharge, a detailed instruction sheet outlining recommendations is provided to the patient. Highlights of a few of these postrhinoplasty recommendations are included in Follow-up care.

Patients are educated preoperatively regarding the temporary postrhinoplasty periorbital and nasal swelling and discoloration that may occur. Besides providing emotional support during the immediate postoperative period, remind the patient again that edema and ecchymosis usually clear within 2-3 weeks. In certain patients, a complete resolution of edema may take as long as 6 months. Supratip edema can be treated with small injections (0.3 mL) of Kenalog 20 starting at week 3 and continuing once a month. These injections must be placed deep to minimize the risk of dermal atrophy and tissue loss.

After cast removal, the nasal skin is gently cleansed with an adhesive solvent and gauze. At this visit, photographs may be taken to document the early postoperative surgical result. These early photographs may assume vital medicolegal importance if the patient's surgical result is compromised by subsequent trauma. Analysis of early postoperative results is also of educational value to the surgeon. The author likes to arrange visits 1, 3, 6, 9, 12, 18, and 24 months after the operation. After that, annual visits are encouraged and photographs are taken to document the subtle changes in nasal appearance that inevitably occur with time. Observing and studying these changes (both favorable and unfavorable) provides the surgeon with an invaluable education. Such an approach can allow surgeons to continuously analyze their techniques to anticipate, control, and favorably affect long-term rhinoplasty healing.

A brief summary of postrhinoplasty recommendations given to patients is as follows:

• Prevent injury to your nose. Minimize all activities, and be very careful.

• Avoid blowing your nose. Wipe your nose gently with tissues. If you sneeze, try to keep your mouth open.

• Change the dressing (if you have one) under the nose as needed.

• Avoid extreme physical activity. Strive for more rest than usual, and avoid exertion.

• Brush your teeth gently with a soft toothbrush only.

• Avoid manipulating your upper lip, which helps keep your nose at rest.

• Avoid smiling or excessive facial movements for 1-2 weeks.

• Wear clothing that fastens in front or back for 1 week. Avoid slipover sweaters, tight tee shirts, and turtlenecks.

• Avoid foods that require prolonged chewing. This is the only dietary restriction related to the rhinoplasty.

• You may wash your face, but avoid getting the nasal cast wet.

• Do not wash your hair for 1 week, unless you have someone who can do it for you.

• Do not get your nasal dressing wet.

• Absolutely avoid tanning for 6 weeks after surgery.

• Do not wear regular glasses or sunglasses that rest on the bridge of the nose for at least 4 weeks. You may tape the glasses to your forehead.

• After the physician removes your nasal plaster cast, the skin of the nose may be cleansed gently with a mild soap or a hypoallergenic/mild skin lotion.