Short Nose Rhinoplasty Treatment & Management

When the short nose is caused by an active underlying etiology, whether infectious, autoimmune, or neoplastic, treat the underlying cause before initiating surgical therapy. Therapy for the disorders that cause short nose deformity is beyond the scope of this article.

If there is no history of underlying disease or trauma, one may consider a cosmetic rhinoplasty for the short nose. Probably the most common type performed worldwide is one in which an L-shaped silicone strut is introduced over the dorsum, tip, and columella via a closed approach. It is best tolerated in patients with a thick skin-soft tissue envelope and relatively strong cartilages. Extrusion of the implant is possible, but unlikely. ^{[4, 5]}

Many short noses are the result of trauma, and sometimes the surgeon may be able to address the trauma acutely. Existing lacerations may be used for access. Re-establishing normal anatomic relationships and stabilizing support structures within the nose are important. This is generally easier to accomplish during the first 14 days after injury because scar contraction has not yet occurred. Conversely, the bony support of the nose may be unstable, and using rigid or semirigid fixation with plating systems often is necessary. Acute saddle nose fractures can be fixed with a Kershner wire through the perpendicular plate and the frontal processes of the maxilla.

When bone is absent or severely comminuted, bone grafts may be required. Calvarial bone grafts are good options when support in the upper bony and lower cartilaginous dorsum is lost. Drain hematomas and splint appropriately. In patients with acute trauma, when the skin–soft tissue envelope has no underlying support, this envelope contracts during the healing phase, and the short nose must be treated secondarily.

When treating the short nose or saddle nose of long duration, 3 key principles are observed: extensive undermining of skin, restoration of structural support, and if indicated, release of internal lining. Wide dissection of the nasal skin is necessary because it is needed for redraping. Carry out undermining beyond the pyriform aperture and up to the radix. Take care not to perforate thin scarred skin. Antibiotics are recommended for major nasal reconstructions, especially with the use of alloplasts or when internal lining is torn.

Open approach

The open approach is useful for the short nose, both in the acute phase and later. This approach involves making marginal incisions that are joined at the midcolumellar level by a skin incision. This allows the surgeon to raise the skin and soft tissue of the lower third of the nose and visualize the cartilages in situ. The open approach is particularly useful in the patient with the short nose because grafting, visualization of existing cartilage deficits, and use of both hands is important. In contrast to the closed approaches, the open technique allows direct visualization, binocular vision, and bimanual manipulation of structures. Tip grafts, onlay grafts, and struts can be carved to exact specifications and stabilized in precise positions without risk of moving or shifting. It allows the operator greater precision while addressing the cartilaginous dorsum and upper lateral cartilages.

Closed approaches

Closed approaches also can be used to treat the short nose. With these methods, mucoperichondrial flaps are raised on each side of the septum, back cuts are made, and the flaps are advanced anteriorly and inferiorly. Transfixion incisions are performed to release the lower lateral from the upper lateral cartilages. Batten grafts may be inserted through hemitransfixion incisions in the membranous septum to push the nasal tip in a caudal direction. When the mucosa between the upper and lower lateral cartilages needs to be cut, and as the lower lateral cartilages are moved caudally, a gap may appear. This gap can be filled with a conchal cartilage composite graft. Using composite or full-thickness skin grafts in the membranous septum to advance the columella is possible.

Graft and implant materials

Release of the upper lateral cartilage from the septal remnant may be important when the septum has collapsed. Separating the upper lateral cartilage from the nasal bones also is possible, but a filler graft must be used to hide the potential depression. Staggered incisions also may be required in septal mucoperichondrium to allow anterior displacement of the tip. Further nasal lining release is accomplished by dissecting mucoperichondrial sleeves from the septum and from beneath the nasal bones back to the nasopharynx. In the presence of congenital absence of bone, osteotomies may be made around the nasal bony pyramid and the nasal tissues advanced forward. Interpositional grafts may be placed through sublabial and/or coronal approaches.

Because the nasal septum is critical in providing integrity to the cartilaginous dorsum and the tip, begin restoration of the nasal framework with reconstruction of the septum. The position of the septal angle is a key determinant of nasal tip rotation and projection. In addition, the septum provides cartilage graft material needed for many short noses. Performing a septoplasty prior to setting the nasal tip and reconstructing the dorsum is wise. If necessary, the upper lateral cartilages can be dissected sharply from the dorsal septum, but care should be taken not to injure the mucosa on each side. Spreader (batten) grafts formed from small strips of septal cartilage may be sutured between the medial borders of the upper lateral cartilages and the septum to alleviate twisting or narrowing of the nasal valve area. ^[6]

These grafts also may be used to improve nasal function in the area of the valve. The angle of attachment of the upper lateral cartilage to the septum must be greater than 10°. If the angle is too acute, as is common in the short nose, spreader grafts are indicated. ^[7] Secure the spreader grafts in mattress fashion, with semipermanent sutures, to the upper lateral cartilages and septum. Do not place spreader grafts until the osteotomies are completed.

Septal cartilage is the preferred graft material for the short nose because it is readily available, resilient, and resists rejection and resorption. However, in the short nose, septal cartilage is usually limited, particularly when it is necessary to leave behind adequate dorsal and caudal septal cartilage support for the tip. ^[8]

Cartilage grafts harvested from the conchal bowl differ from their septal counterparts. Auricular cartilage is softer, more brittle, and more convoluted than septal cartilage. The curvature of auricular cartilage makes it an attractive option for battens replacing the lateral crura, but its shape and limited availability make it unsuitable for larger dorsal defects. A slightly increased (< 5%) infection rate is associated with auricular cartilage grafts. Nevertheless, cartilage from the concha cymba, concha cavum, or both may be used to act as dorsal onlays or dorsal or caudal struts. Rarely is enough cartilage available to reconstruct all 3 areas. Curvature of the grafts may be negated by folding the graft and suturing the halves together.

For large saddle defects involving bony and cartilaginous dorsum, rib cartilage makes excellent graft material. Follow-up study demonstrates that rib cartilage maintains its bulk as long as 48 years after surgery. Rib cartilage should be carved so that equal amounts of perichondrium are removed from both sides to discourage warping. Warping is particularly noted in children's cartilage, but in older patients the cartilage is partly calcified; therefore, the warping tendency is not noted as much in older patients. Rib cartilage grafts with large cross-sectional areas tend to become warped less frequently. The cartilage may be carved into 3 pieces. One piece is placed as a dorsal strut, the second acts as a columellar strut, and the third as the dorsal onlay. The columellar strut is grooved to fit into the dorsal strut. This configuration resists posterior displacement of the tip and dorsum.

Rib grafts containing both cartilage and bone also may be used. These grafts typically are obtained from the 9th, 10th, or 11th rib. The bony portion may be fixated with screws or k-wires. Mutaf has described a technique for saddle nose correction known as anatomic replication (ART). ^[9] A larger graft, from the fifth rib, is harvested and carved in such a way to replace missing bony dorsum, dorsal strut, caudal strut and upper lateral cartilages. Since all the components remain attached, there is less likelihood of postoperative displacement. Drilling the nasal bones down and drilling the bony undersurface of the onlay graft may add long-term stability. ^[10] Osteotomies, if needed, are performed in such a way to minimize disruption of the overlying periosteum.

In a retrospective study of 36 Asian patients with short nose deformity (either congenital or secondary to previous rhinoplasty), Park et al found that the key lengthening procedures performed consisted of the use of septal extension grafts (reinforced with extended spreader grafts), dorsal onlays, and tip grafts. The investigators reported that all of the study’s patients were satisfied with the cosmetic results of the surgery and that no serious complications arose. They also reported that a better increase in the distance from the nasion to the tip-defining point was achieved with rib cartilage than with septal or conchal cartilage. ^{[11, 12]}

In another study of Asian patients with short nose deformity, Kim and Kim also reported the successful use of rib cartilage grafts to obtain septal extension. In the study, which included 38 patients, external nose lengths increased by an average of 8 mm from the nasal root to the tip. ^[13]

When autologous cartilage is in limited supply, surgeons have made use of other biologic materials in short nose rhinoplasty. Banked demineralized bone has an unacceptably high absorption rate. Concern also exists about transmission of human immunodeficiency virus (HIV) and of slow viruses with homografts.

Although HIV transmission has been reported with banked homograft bone, no cases have been reported with banked irradiated cartilage. Irradiated homograft cartilage has demonstrated satisfactory results when used in the nose, as opposed to other areas of the face. ^[14] Large series (in which irradiated homograft cartilage has been used in the short nose) have documented low rates of warping, infection, and resorption over many years. ^[15] Columellar struts and dorsal onlay grafts have been found to fare better than tip grafts. ^[16] Freeze-dried bone has also shown good success in maintaining projection at 5 and 10 years. ^[17]

Dermal allografts (eg, AlloDerm) are inert biologically. Because the normal human dermal architecture is preserved, native vascular ingrowth is rapid. However, with dermal material, structural rigidity is a problem, and dermal allografts are probably best considered to camouflage dorsal irregularities. Studies are indicating that the retention rate of homograft dermis is about 50% at 1 year. A better option in patients with thick skin–soft tissue envelopes may be to excise the nasal superficial musculoaponeurotic system (SMAS) en bloc from the tip and supratip areas and use it to augment the dorsum.

Bone grafts are useful in the short nose because they replace structurally important elements and adequately resist the forces of postoperative scar contraction. Rib and iliac crest grafts, such as endochondral bone, undergo a higher rate of resorption than the membranous bone of the calvarium. Iliac bone grafts are associated with a painful donor area for 2-3 weeks. Rigid fixation may help retard the rate of bone resorption. Donor site pain in the chest and hip is somewhat higher than that in the skull. Therefore, consideration of outer table calvaria as the primary source of bone graft for augmentation of the short nose is recommended.

Calvarial bone is strong and thin. Grafts can be thinned to 1 mm. These grafts can be used as battens for nasal valve collapse, as dorsal grafts for saddle nose deformities, and as columellar struts. Calvarial bone is especially useful in noses with severe loss of tip support due to absence of the dorsal and caudal septal strut. Grafts may be secured with wire or with microplates and screws. Calvarial bone grafts may have a rigid appearance and feel. Theoretically, rigid bone grafts in the lower third of the nose may erode through the soft tissues and may be subject to fracture.

In the past, synthetic substances have been widely used for dorsal augmentation. Infection and extrusion rates have varied.

Extruded polytetrafluoroethylene (ePTFE) is an excellent material for dorsal augmentation because of its high tissue compatibility. Although it is porous, significant tissue ingrowth does not occur. The material may be stacked in multiple layers and sutured into position with the open approach. An infection rate of 3.2% has been reported. ^[18] . It is not recommended for use when a septal perforation is present. When placing ePTFE, the area of dissection must be large enough to avoid rolling or bunching. Let the graft run the entire length of dorsum to avoid a postoperative step-off. The material should be soaked in antibiotics prior to placement. Fresh gloves and instruments should be used to manipulate the implant. Because ePTFE is soft, it is better used as a filler than as a strut. Infection or capsular distortion also can be a problem.

Calcium hydroxylapatite in a carrier-based gel (Radiesse) has been used as an injectable material successfully for small dorsal depressions.

In summary, alloplasts are best used in the at-risk nose only when autologous material is not an option. Broad-spectrum antibiotics should be used perioperatively. Multiple intranasal incisions increase the risk of infection. In soft tissues under tension, especially in the nasal columella and tip, alloplastic implants should be avoided.

Procedure

The nasal tip may be thought of as a tripod. The 2 lateral crura form the cephalic limbs of this tripod, and the paired medial crura form the inferior limb of the tripod. Reducing the length of the lateral crura and/or increasing the length of the medial crura cause the tip to rotate superiorly (see the image below). Conversely, reducing the length of the medial crura and/or increasing the length of the lateral crura cause the tip to rotate inferiorly. If all 3 legs are shortened symmetrically, the tip does not rotate, but projection decreases. If all 3 legs are augmented to the same degree, tip projection increases.

Other techniques attempt to alter tip rotation by moving the position of the dome. For instance, creating a new dome several millimeters lateral to the old one effectively shortens the lateral crus, and it lengthens the medial crus by the same amount. With this technique, the cartilage is softened and a new surgical dome is created by placing mattress sutures through the cartilage at the desired point. If the nasal tip is underprojected, as is often the case with the short nose, leaving lateral crural length intact when achieving upward rotation is preferable. In these cases, the middle leg of the tripod must be lengthened. This most commonly is performed with a cartilage strut. Struts usually are fashioned from septal or auricular cartilage and are secured between the medial crura with dissolvable sutures that traverse the vestibular skin (see the image below).

Further lengthening of the middle leg of the tripod may be achieved by using a columellar-septal suture. This technique secures the medial crural strut complex to the septum in a more projected fashion. Use of a tip graft also may affect rotation and projection. Septal and auricular cartilage grafts are the most common grafts used for this purpose. To decrease rotation, the graft should be sutured into position slightly caudal to the tip-defining cartilage (the caudal border of the domal cartilage). Four 5-0 or 6-0 polydioxanone or clear nylon sutures are used to secure the graft. Tip grafts may be stacked upon one another to increase the effect. Septal cartilage tip grafts have been demonstrated to have long-term survival in 95% of patients. Tip grafting is not recommended in patients with thin skin unless the graft is made of auricular cartilage, is beveled meticulously, or is covered with a thin fascia graft. In patients with thick skin, thicker and more angulated grafts may be used.

Because of the forces of scarring in the healing nose, downward rotation of the tip is more difficult to achieve than upward rotation. The technique used depends on the strength and availability of the cartilages, the thickness of the skin, and the amount of projection present. For instance, the lateral crus may be lengthened by cartilage or composite grafting (see the image below). In addition, the dome may be moved to a more medial position by cartilage-stealing techniques. Alternatively, the medial crura may be shortened by transverse excision, a procedure that is rarely necessary in the short nose.

The septal angle may be moved in a caudal direction with a caudal extension graft. This is a triangular piece of cartilage, the base of which lies along the dorsal plane. In cases in which derotation (ie, downward rotation) is desired, freeing the lateral crura from their attachment to the pyriform apertures and upper lateral cartilages may help. If a rent occurs between the upper and lower lateral cartilages during downward positioning of the tip, a composite graft taken from the concha may be necessary.

Resection of the posterior caudal septum, rotation and stabilization of the lower lateral cartilages in an inferior direction, and internal and external postoperative nasal splinting may effect sufficient lengthening in many short noses. A long dorsal graft may move the nasion superiorly and push tips caudally. A flying buttress graft is a single or paired extended spreader graft secured to a columellar strut. A further development of this concept is the dynamic adjustable rotation tip tensioning technique. This technique involves 2 battens secured on either side of the septum and the columellar strut. Suturing the battens to the septum once proper tip positioning is accomplished makes adjustment of tip rotation and projection possible.

A similar method, using 2 slips of bone, takes advantage of the strength of calvarial bone. One piece is perforated and secured between the medial crura as a columellar strut. A second piece is used as a dorsal strut. If dorsal augmentation is needed, the dorsal strut extends from the nasion to tip and is secured to the underlying bone with lag screws.

If no bony dorsal augmentation is needed, the dorsal bone is fixated to the nasal bones in an end-to-end fashion using a miniplate. A slot is drilled in the caudal end of the dorsal bone strut so that the 2 calvarial bone grafts interdigitate in a tongue-in-groove fashion (see the image below).

A small titanium screw on the columellar piece acts as a stop to prevent retrodisplacement of the bones as scar contraction occurs. A cartilage tip graft is usually necessary to camouflage the corners of the bone grafts. The length of the columellar piece may be reduced and the slot lengthened to adjust rotation and projection of the tip.

Nasal tip projection depends not only on the 3 legs of the nasal tripod but also on the position and integrity of the septal angle and the fibrous attachments between the lower lateral cartilages and the septum–upper lateral cartilage complex. The position and integrity of the septal angle, in turn, depends on the presence of strong dorsal and caudal cartilaginous struts and an intact nasal spine. These conditions are typically absent to one degree or another in the short nose.

As discussed, tip projection may be increased by lengthening the medial crural support using a cartilaginous strut or by advancing the columella along the septum with a septocolumellar suture. Theoretically, cartilage grafting to the 3 legs of the tripod can be performed to increase projection, but in practice this does not produce a tripod strong enough to withstand the forces of scarring. Tip grafts also may be effective in increasing projection, especially when placed directly over the caudal border of the dome cartilage. When the skin is particularly thick, more than a single layer of cartilage may be necessary.

Once the nasal tip has been modified, the surgeon is able to address the dorsum more accurately. In the short nose, dorsal augmentation of both the cartilaginous and bony dorsum often is indicated. Need for dorsal reduction rarely is encountered in this situation and is addressed in other Medscape Reference articles. Following repositioning of the nasal bones, the upper lateral cartilages may be freed from both the septum and nasal bones, and sutures may be secured into more appropriate positions. If the septum remains deviated at the rhinion, cartilage-scoring methods or dorsal spreader grafts can be used.

For significant dorsal deficiencies, graft material must be shaped, inlaid, and secured. For mild-to-moderate deficiencies in the cartilaginous or bony dorsum, flat, beveled pieces of septal or auricular cartilage are placed deep to the skin–soft tissue envelope. Small dorsal irregularities are treated by carving oval pieces of cartilage and morcellating them. Securing these grafts either to the periosteum of the nasal bones or to the upper lateral or septal cartilages with permanent sutures is helpful.

Craniofacial techniques for nasal lengthening take advantage of sublabial and coronal approaches. Osteotomies are performed around the pyriform aperture so that the bony nasal pyramid may be advanced forward. The nasal lining is divided, and interpositional bone grafts are secured. Flaps from the buccal sulcus may be used to fill defects caused by mobilizing the lower lateral cartilage anteriorly. Some patients, particularly those with congenital short noses, may be candidates for LeFort advancements. In such cases, advancement of the maxilla should be carried out prior to the short nose rhinoplasty.

Lengthening the short nose may be accomplished by moving the nasal frontal angle in a cephalad or anterior direction. This can be achieved with grafts made of the same materials used for dorsal modification. Often, the radix is augmented simply by extending the dorsal graft in a cephalad direction. When radix grafts are placed independently, the best approach is to dissect as small a soft tissue pocket as possible and fixate the grafts with internal or external sutures or with screws.

Marianetti et al described the caudal septum pivot (CSP) technique for short nose rhinoplasty, which, in a retrospective study, they suggested could be an effective alternative to the classic septal extension graft in selected patients. CSP surgery involves insertion of a graft into “the dorsal septum after its division using as pivot the caudal portion, without detaching it from its natural anchorage to the anterior nasal spine.” Comparing patients treated with the CSP technique with those who underwent classic septal extension grafting, the investigators found that at 1-year follow-up, patients in both groups demonstrated a statistically significant decrease in the nasolabial angle, with increases in tip projection and nasal length. ^[19]

After appropriate modification of the internal lining and skeletal framework, the skin and soft tissues are replaced in their anatomic positions and the incisions are closed. Proper taping and splinting help reduce the amount of postoperative swelling. A dorsal splint is placed over a tape dressing to protect the nose and to ensure proper reduction of the nasal bones. The splint also helps prevent swelling in the supratip. Several different types of dorsal splints are available, including plaster, plastic, and metal. Septal splints have been demonstrated to reduce the necessity for revision septal surgery. Packing the nose is rarely necessary. Sutures and internal and external splints are removed approximately 5-8 days later.

Bruising, swelling, and numbness typically are more marked for short nose rhinoplasty than for other rhinoplasties because undermining is usually more extensive. If an open approach is used, tip edema and paresthesias may not resolve completely for 6-12 months.

When robbed of its underlying support, the natural tendency of the nose is to heal in a collapsed, upwardly rotated position. This tendency makes rhinoplasty of the short nose a particular challenge, and it demands that the surgeon extensively undermine both skin and nasal lining and take pains to reconstitute a stable nasal superstructure. If short nose rhinoplasty is successful, dramatic improvement in function and appearance results.

The primary complications of the short nose rhinoplasty include bleeding, infection, extrusion of implant materials, scarring, and unacceptable cosmetic results. Further surgery is occasionally necessary. Intracranial complications have been reported at the calvarial bone harvest site, and pneumothorax is possible with the harvest of rib cartilage.

The first 6 months following the procedure are critical. During this time, the forces of scarring act against the reconstructed underlying skeletal support. This is also the critical period for healing of the internal lining. Nerves and lymphatics continue to heal for up to a year. Further scar remodeling is observed for 12 months. If a patient is satisfied with function and cosmesis 1 year after surgery, the chances for long-term success are excellent.

In the future, new alloplastic implant materials likely will be developed for use in the treatment of the short nose deformity. No doubt the future also will bring controversy as to which, if any, of these materials will act as suitable substitutes for autologous tissue. Growth factors currently are being developed to promote angiogenesis, promote bone development, and improve wound healing.