Osteotomy Rhinoplasty

Most, although not all, rhinoplasties require the use of a form of osteotomy, because most standard rhinoplasties require the movement or alteration of the osseocartilaginous vault that composes much of the nose. For information on various rhinoplasty techniques, see the following Medscape Drugs & Diseases articles:

• Rhinoplasty, Alar Cartilage Resection

• Rhinoplasty, Asian

• Rhinoplasty, Augmentation

• Rhinoplasty, Basic Closed Technique

• Rhinoplasty, Basic Open Technique

• Rhinoplasty, Maxillary Augmentation

• Rhinoplasty, Spreader Grafts

• Rhinoplasty, Supratip Deformity

• Rhinoplasty, Tip Approaches

• Rhinoplasty, Tip Surgery

• Rhinoplasty, Tripod Theory

• Rhinoplasty, Turbinate Reduction

Frequency

In 2018, according to statistics from the American Society of Plastic Surgeons (ASPS), more than 213,000 rhinoplasties were performed in the United States.[1]  For each of these surgeries, possibly 2-4 osteotomies were performed.

In general, indications for osteotomies in rhinoplasty are anatomic findings of a high nasal dorsum that requires "hump" removal, an "open roof" after the hump has been removed, and a wide nasal base. Correcting these conditions requires osteotomies. Understanding these factors requires a familiarity both with the basic anatomy of the nose and surrounding facial and cranial structures and with the goals of aesthetic (cosmetic) and functional rhinoplasty.

Simplistically, the nose is a structure consisting of a bone and cartilage framework over which is draped a skin envelope. The size, shape, quality and/or thickness, texture, and position of the various parts help determine the appearance and function of the nose. The bony portion is referred to as "the bony vault." According to Oneal, Izenberg, and Schlesinger, "[It] … consists of the paired nasal bones and the frontal ascending processes of the maxilla. The vault is generally pyramidal in shape… The most narrow part of the bony pyramid is at the intercanthal line… Laterally the nasal bones articulate with the ascending or frontal process of the maxilla…"[2] Surgeons who perform rhinoplasties need to have a thorough understanding of nasal anatomy.[3] Refer to the images shown below.

Nasal bones with outline of medial and lateral osteotomies.

Another view of nasal bones.

Contraindications for osteotomies lay within the contraindications for rhinoplasty. If the surgeon feels the patient is an appropriate candidate for rhinoplasty, osteotomy can be performed.

Aesthetic contraindications may exist wherein the nasal vault does not require narrowing and, even after hump removal, the lateral nasal bony plates lie in close enough approximation that osteotomy is unnecessary. Such decisions are within the purview of the individual rhinoplastic surgeon.

Every patient must undergo an appropriate and complete medical history and physical examination prior to rhinoplasty/osteotomy. The following laboratory tests should be included:

• CBC
• Urinalysis
• Electrolytes
• Electrocardiogram (for men >40 y and women >50 y, unless a history of hypertension, stroke, arrhythmia, diabetes, or smoking, or any other concerning reason, is present)
• Pregnancy test in women of childbearing age
• Human immunodeficiency virus (HIV), hepatitis B, and hepatitis C testing

Obtain a chest radiograph when none has been performed for more than 1 year, if the patient has a history of smoking or prior disease or if one is indicated by age.

Except for correction of nasal fractures or airway difficulties, rhinoplasty is an elective procedure chosen for aesthetic purposes.[4] In these situations, ultimately, the patient is the one who decides to proceed with surgery.

A study by Chen et al surveying 172 members of the American Academy of Facial Plastic and Reconstructive Surgery found that 87% reported “always” or “mostly” using intranasal lateral osteotomy in rhinoplasty, compared with just 8% who reported “always” or “mostly” using percutaneous lateral osteotomy.[5]  For additional information on aesthetic procedures, visit Medscape's Aesthetic Medicine Resource Center.

Preoperative photography of the patient is essential prior to rhinoplasty. Take photographs of the frontal view, in profile, and as a caudal-to-cranial image to demonstrate the columella and septum. Review these photographs preoperatively with the patient to discuss the areas with which the patient is dissatisfied.

Digital photography in conjunction with computer programs that allow patients to see possible operative results has become popular. Surgeons using these programs to demonstrate probable operative results need to emphasize to the patient that the depicted results are simulations and do not guarantee final postoperative results. Individual healing and scarring may alter the final results and the patient should be made aware of this possibility.

In general, rhinoplasty can be performed as an outpatient procedure if the patient has adequate arrangements for transportation home as well as aftercare. The choice of anesthetic (general vs local with intravenous sedation) does not affect the patient's choice of ambulatory surgery. Unless other mitigating circumstances are present, the surgeon's preference determines the choice of anesthetic.

Either the surgeon or the patient's primary care physician should perform the usual and customary preoperative workup, including laboratory work, history and physical examination, and other studies that may be appropriate given the patient's health status. Inform the patient which medications (prescription, homeopathic) to avoid (eg, aspirin and aspirin-containing medications, ibuprofen, blood-thinning medications or anticoagulants, vitamin E, fish oil capsulates, and most over-the-counter nutritional agents) and to avoid alcohol for several weeks prior to surgery.

Osteotomy generally is the last step performed in a rhinoplasty since osteotomies can result in considerable oozing from the fractures. If performed at the end of the procedure, the surgeon then can close the incisions rapidly and place a dressing that allows pressure to be applied to help stop the bleeding. An osteotomy performed at the end of the rhinoplasty also results in less postoperative edema.

Lateral osteotomies are performed along the frontal process of the maxilla, occasionally extending onto the nasal bone. Prior to performing the osteotomies, anesthetize the areas where the osteotomies are to take place with local anesthetic with epinephrine. This helps reduce postoperative pain and bleeding.

Using an osteotome (beginning surgeons may choose to use a guided osteotome as they provide easier localization of the sidewall of the nose), produce a fracture line beginning at the piriform aperture (as shown in the image below) and extending to the level where the maxilla meets the frontal bone.

Lateral osteotomy via piriform aperture.

After this is performed bilaterally, manual pressure can be exerted to infracture the bones, thus producing a narrower base and closing an open roof left by removing a hump.

If the nasal bones are thick or if the infracturing is difficult, it may be prudent to perform medial and/or superior osteotomies.

Lateral osteotomies also may be performed percutaneously (see the image below) rather than through the piriform aperture.[6, 7, 8] Using a 2- to 3-mm osteotome, multiple perforation may be created along the proposed fracture line along the side of the nose. Once again, exert manual pressure to infracture the bones, thus creating a narrower base.

Percutaneous lateral osteotomy.

Medial osteotomies are performed to help ensure that fracture lines occur as desired by the surgeon as depicted by the images below. Guide a small osteotome along the nasal septum and drive it up to the level of the nasal process of the frontal bone, thus freeing the nasal bone and facilitating its infracture.

Medial osteotomy being performed during rhinoplasty.

Nasal bones with outline of medial and lateral osteotomies.

Superior osteotomies may be performed when the nasal bones are unusually thick and concern for an unfavorable fracture line connecting the lateral and medial fracture lines exists. Direct percutaneous puncture of the skin using a small osteotome allows for the production of a superior fracture line that may be infractured using manual pressure.

After completion of the osteotomies and infracturing of nasal bones, close all incisions rapidly and apply a nasal splint to prevent movement of the bones after remodeling the bony structures.[9]

A literature review by Tsikopoulos et al indicated that in patients undergoing rhinoplasty, the use of lateral osteotomy with piezoelectric ultrasound waves is associated with less postoperative pain, edema, ecchymosis, and intraoperative mucosa injury than is conventional osteotomy employing a chisel.[10]

Leave the nasal splint in place for approximately 1 week so that fracture stabilization and healing can occur. The splint and any permanent sutures may be removed after 1 week. Usually, no further dressing is necessary.

The patient can expect to experience a minimal amount of bleeding from the nose, which should stop 12-24 hours postsurgery. Advise the patient to expect black and blue discolorations around the eyes, which result from the bruising caused by the osteotomies. Reassure the patient that this resolves in 1-2 weeks.

Advise moderate physical activity immediately after surgery. The patient may resume strenuous physical activity within weeks of surgery; however, since the fracture lines remain delicate, and bony union requires approximately 6 weeks, certain vigorous physical activities (eg, jogging, horseback riding, skiing) should be avoided during this time. Additionally, activities that risk nasal trauma should be avoided during this time. Once bony healing has occurred, the nasal vault should be almost as resistant to fracture as it was preoperatively.

Following rhinoplasty, the soft tissue of the nose develops firmness that gradually resolves over the course of about 1 year. The physical appearance is close to normal after several months and usually changes only slightly as the final tissue firmness resolves.

Observe the patient on a regular basis after surgery to ensure proper postoperative healing. Ultimately, at 1 year, the patient can expect to see his or her final operative results. Take postoperative photographs to demonstrate the results of the operations.

Unlike soft-tissue complications from rhinoplasty, which require several months for soft-tissue swelling to resolve prior to corrections, many problems resulting from osteotomies may be addressed earlier, depending on the problem.

Obvious problems with asymmetry may be corrected by refracturing the nasal bones and resplinting the fractures. Once again, caution patients to avoid activities that may cause shifting of the bones and to vigilantly leave the splint in place to allow for proper healing of the osteotomy sites.

A stair-step deformity occurs when lateral osteotomies have been placed too high and a prominent ridge along the lateral aspects of the nose develops. Correction of this deformity can be performed either by fracturing the ridge and resetting it or by rasping down the bony ridge through a tunnel created from the piriform aperture.

The patient can expect a fair amount of bruising and swelling in the immediate postoperative period. Until they have resolved, these symptoms may mask the final result of the osteotomies.

Once the swelling and bruising have resolved, the patient is able to discern a narrower nasal base that complements the new contours of his or her nose. Unless osteotomies are unset or rebroken from physical force, natural healing of the bones occurs.

A study by Al Abduwani and Singh indicated that in patients undergoing open rhinoplasty for a severely deviated nose deformity, risk of the deformity’s recurrence or of a remnant deformity is increased if the osteotomy is omitted or performed just unilaterally.[11]

A study by Simsek and Demirtas suggested that in patients with obstructive nasal deformities, open septorhinoplasty can relieve the symptoms of obstruction whether or not the procedure includes osteotomy. The study included 40 patients with a wide nasal dorsum and prominent hump and 35 patients with a narrow nasal dorsum and a minimal hump, with the first group undergoing septorhinoplasty with lateral osteotomy and the second group being treated with septorhinoplasty without osteotomy. Both groups demonstrated a similarly significant postsurgical reduction in nasal obstruction, as evaluated with the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire.[12]

A study by Jeong et al indicated that in East Asian patients undergoing aesthetic rhinoplasty, a combined paramedian oblique (ie, a form of medial) and percutaneous lateral osteotomy can effectively reduce broad nasal bones, creating a stable framework and leading to good outcomes when silicone augmentation is simultaneously employed. The investigators found a significant increase in the average Rhinoplasty Outcome Evaluation questionnaire score, with postoperative results scored as better than good by 91.2% of patients.[13]