Saddle-Nose Rhinoplasty Treatment & Management

Medical treatment applies only to limiting the progression of those disease states that lead to cartilage destruction and eventual saddling. Diseases such as Wegener granulomatosis and relapsing polychondritis should be managed with the help of medical specialists (rheumatologists). In most individuals with saddle-nose deformities, treatment is aimed at surgical reconstruction of functional and aesthetic deficits.

Depending on the degree of saddling, different reconstructive options can be used. Decisions regarding nasal reconstruction are concerned both with the choice of materials to be used and the type of reconstruction needed.

The history of nasal reconstruction is full of nasal implants and grafts taken from a variety of sources. The interesting list of grafts and implants used in reconstructing the nose seems almost limitless. Some historic grafts and implants used in the human nose include the following:

• Autografts - Auricular cartilage, rib, patient's finger ^[11]

• Homografts - Irradiated rib, pooled acellular dermis

• Xenografts - Leather, duck's sternum, bovine cartilage

• Precious metals - Titanium, gold, silver, metal alloys

• Inert bioimplants - Coral, ivory

• Synthetic compounds - Silicone, polytetrafluoroethylenes, polyamide mesh

Variable rates of success and failure have been noted with different implants and grafts. The selection of material in nasal reconstruction should center on balancing long-term biocompatibility, infection rates, extrusion rates, graft resorption rates, graft harvest site morbidity, and material availability. The ideal implant's profile satisfies all of these concerns. The ideal nasal implant has yet to be developed.

The ideal nasal implant should have certain characteristics, as follows:

• It is noncarcinogenic.

• It is nonimmunogenic (no foreign body or inflammatory reaction).

• It is nonresorbable.

• It is easy to work with and malleable.

• It has a tactile feel similar to that of tissue (cartilage).

• It has a low or zero extrusion rate.

• It allows biointegration of the implant with the surrounding tissue.

• It is cost effective.

In a systematic review involving patients with Wegener granulomatosis–related saddle-nose deformity, Ezzat et al reported that the deformity can be safely and effectively corrected with rhinoplasty. The surgery (primary and secondary) was successful in 37 out of 44 study patients (84.1%), with the complication rate found to be 20%. The procedure was most effective when a single L-shaped strut graft composed of autologous tissue was used, as opposed to individually placed grafts. ^[12]

Another systematic review, by Coordes et al, also found rhinoplasty to be safe in Wegener granulomatosis patients with saddle-nose deformity (with all members of the study group having minimal or no local disease at the time of their procedure). However, the investigators found that the likelihood of revision surgery was greater in individuals with Wegener granulomatosis than in rhinoplasty patients without the disease. ^[13]

Autogenous materials

Autogenous materials are always preferred to alloplastic implants as far as infection rates, extrusion rates, and biocompatibility issues are concerned. Septal cartilage is the best choice but is often not present in sufficient quantity. Secondary sources of autogenous cartilage include auricular and rib cartilage. Cartilage harvested from the ear is especially well suited for use in the nose. Bone grafts harvested from calvarial, iliac, and tibial bone sources can be used. Autogenous soft tissue materials include dermis and fascia.

Homografts

Homografts are harvested from healthy screened donors. Irradiated cartilage and sheets of pooled acellular dermal allografts (AlloDerm; LifeCell Corp, Houston, Texas) are the homografts most commonly used in nasal dorsal reconstruction.

Alloplasts

Synthetic implants offer the advantages of ready availability. However, in the nose, alloplasts have a tendency to behave like foreign bodies, with higher rates of infection, extrusion, and inflammatory reactions, as compared with those of autogenous grafts. Moreover, although alloplasts are well suited as filler material, most do not provide significant structural support to the nose.

Commonly available alloplasts include polyamide mesh (Mersilene; Ethicon, Sommerville, New Jersey), silicone-based implants (Silastic; Dow Corning, Midland, Michigan), expanded polytetrafluoroethylene (ePTFE) (Gore-Tex; WL Gore and Associates, Flagstaff, Arizona), and porous high-density polyethylene (PHDPE) (Medpor; Porex Surgical, Newnan, Georgia). ^[14]

Proponents of alloplasts note that autogenous cartilage grafts are fraught with problems that must be considered. As mentioned before, septal cartilage is often of low quantity or nonexistent. Auricular cartilage is available; however, it is curved, it can potentially warp with time, it is of limited quantity, and it involves the morbidity of a second operative site. Rib cartilage is susceptible to warping and involves the morbidity of a second operative site. Also, some surgeons may be uncomfortable with the possible risks related to the thoracic surgical site. Bone grafts have been reported to undergo resorption. They are hard and can also result in donor-site morbidities.

At times, because of a number of factors, including strong patient preference against a second operative site, alloplastic implants may be used. ePTFE has been in use for a number of years, and positive reports have encouraged their wider use. Outcomes pertaining to synthetic implants are discussed in the Outcome and Prognosis section.

PHDPE implants have pore sizes of 125-250 µm, which allow access to immune cells and fibrovascular ingrowth. Sclafani, Thomas, and colleagues (1997) demonstrated the ingrowth of fibrovascular tissue into these porous implants, which confers increased resistance toward implant infection. ^[15] This ingrowth also anchors the implant to the surrounding native tissue.

Despite several promising reports, the long-term viability of these implants has yet to be evaluated. Alloplasts must be recommended only as a last resort and not as a convenient substitute for autogenous grafts. One significant disadvantage of nasal implants includes the changes to the surrounding tissue (scarring, skin atrophy), which may render less-than-optimal results in subsequent rhinoplasties. The authors' hesitancy to use any foreign materials in the nose is based on the authors' and other colleagues' experience with the removal of displaced, infected, or extruding nasal implants placed by other surgeons.

Nasal dorsal reconstruction using autogenous materials

For patients with no nasal airway obstruction and minor-to-moderate nasal dorsal saddling, onlay grafting techniques can be used. These grafts can be fashioned from septal cartilage or auricular cartilage. Onlay grafting can be used to augment the dorsum or to camouflage localized areas of depression. As Tardy described, auricular cartilage grafts can be individually placed as morselized pieces or as laminated or layered grafts. Small-to-medium dorsal depressions can also be camouflaged by using layers of laminated, or sandwiched, ear cartilage placed on the dorsum. Such layered or sandwiched grafts can be used to reconstruct not only the dorsum but also the caudal septum (see the image below).

Conchal cartilage can be used as layered or sandwich grafts to fill defects on the nasal dorsum and to reconstruct columellar support.

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Grafts can be placed via endonasal or external (transcolumellar) rhinoplastic approaches. The precise creation of the subperiosteal pocket can help stabilize the graft placement site. Transcutaneous suture fixation can be used to prevent graft migration. The aesthetic look and the dorsal tactile regularity of the nose can be improved by morselizing the graft edges and by placing a layer of acellular dermis (AlloDerm) on top of the grafts. AlloDerm can be used for camouflaging small dorsal imperfections by providing a layer of cushioning. Alternatively, a layer of crushed cartilage or fascia can also provide a smoother reconstructed dorsum. A properly performed targeted osteotomy can result in the elevation of flat or depressed nasal bones.

Taş described the use of a diced cartilage flap to correct saddle-nose deformity when a diced cartilage graft fails. The procedure, which was performed on seven patients with a gap of less than 1 cm in the lower third of the dorsum, involved undermining the nasal dorsum through the supraperichondrial and subperiosteal plane, with distal release of the diced cartilage island connected to the nasal dorsal skin and transposition of the island to the tip region. The island, in the form of an advancement flap, was moved caudally and sutured to the posterior dome area. ^[16]

Larger defects and deformities affecting the middle vault or the nasal dorsum require a more structural reconstructive approach. Fundamental to reconstructing the moderate-to-severe saddle nose is restoring middle vault function, reversing any internal valve narrowing, and reinforcing nasal tip and dorsal support mechanisms. The placement of spreader grafts is usually sufficient to address the internal nasal valve and middle vault collapse (see the image below).

Spreader grafts are rectangular sculpted pieces of cartilage placed between the upper lateral cartilages and septum. They serve to widen the internal nasal valve, widen the middle vault, and prevent collapse of flail upper lateral cartilages. Also, they can provide additional support to the dorsum.

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More substantial dorsal augmentation (too great for placement of conchal or septal cartilage grafts) can be achieved by using a boat-shaped onlay graft fashioned from rib cartilage (see the image below). The cartilage is carved from the central core of the rib (as opposed to peripheral area) to minimize warping. Adams et al have demonstrated this phenomenon in their elegant studies measuring cartilage warping with time and location of harvest. ^[17] The sculpted graft is placed in a precise pocket and can be suture fixated for additional stability. If nasal tip projection and support structures are deficient, new support structure must be reconstructed.

Rib cartilage can be sculpted to serve as an onlay graft to augment the nasal dorsal contour.

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L-shaped strut reconstruction

The reconstitution of dorsal-caudal and tip support structures can be achieved using the concept of the dorsal L-shaped strut. The L-shaped strut refers to the L-shaped dorsal-caudal nasoseptal support structure that should be present in the nose. An intact septum in the normal, nontraumatized nose sufficiently serves this function. In the structurally compromised nose, new support structures must be constructed. A number of methods can be used to reconstruct a dorsal L-shaped strut.

The patient's own septal cartilage is readily available and well suited for reconstructing caudal and dorsal septal deficits. In patients lacking adequate septal cartilage, other cartilage sources can be used. Costochondral (rib) cartilage from the patient (harvested at the time of nasal reconstruction) can be used to re-create a dorsal L-shaped strut. This L-shaped strut usually has 2 components: a dorsal boat-shaped graft (for dorsal profile) and a columellar support pillar or strut (for nasal tip support; see the image below). The placement of a notch in the dorsal graft to fit the columellar strut can stabilize this connection. The 2 components are suture fixated together. The rest of the nose is reconstructed based on this new support structure. ^[18]

A columellar strut can be assembled with a boat-shaped dorsal graft to reconstruct dorsal-columellar L-shaped strut. Rib cartilage can be used to carve both components of the graft.

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In a similar manner, bone can also be used for reconstruction. Gerow et al and others describe using bone harvested from a rib to reconstruct the dorsal L-shaped strut and to augment the premaxilla. ^[19]

Irradiated cartilage homografts can also be used to reconstruct articulated dorsal and caudal nasal support structures, although long-term resorption may be encountered with irradiated cartilage (as reported by Welling et al). ^[20] As such, the use of irradiated cartilage may be more appropriate in older patients in whom long-term resorption may be less of an issue.

The flying buttress graft combines a single or paired spreader grafts with a columellar strut. In this manner, the newly created L-shaped support structure can address middle vault collapse and internal valve incompetency and can increase tip and dorsal projection. This technique, combined with dorsal onlay grafting, may be used to fix slight-to-moderate middle vault defects along with improving nasal function. Naficy and Baker (1998) describe the use of the flying buttress in lengthening the short nose (a condition often present in the saddle-nose deformities). ^[21] A modified flying-wing procedure has met with success. ^[22]

Remember that the nasoseptal reconstruction must be sufficiently strong and stable to last the entire lifetime of the patient. These goals can be realized in a higher percentage of patients by reinforcing structural and soft tissue elements of the nose in ways that correspond to the defects present and respond to predictable forces of long-term scarring.

Complications encountered after saddle-nose reconstruction can be categorized as medical, functional, or aesthetic. Complications vary with the amount and duration of surgery, the surgical approach to the nose, the amount of dissection, the number of previous surgeries, the use and choice of reconstruction materials, and the intrinsic patient factors.

• Medical complications

  • Infection - Localized cellulitis, abscess formation, infected implant, or infected graft harvest site

  • Perioperative medical events - Atelectasis or pneumothorax with rib cartilage harvest

  • Anesthesia related - Intubation-related injuries

• Functional complications – Nasal obstruction due to inferior migration of spreader grafts, restenosis of the internal nasal valve, iatrogenic septal perforation, or synechia

• Aesthetic complications

  • Graft related - Migration or displacement, warping, visibility of graft through thin skin or with time, or resorption of graft

  • Alloplast implant related - Extrusion, displacement, or unnatural implant contours

  • Transcolumellar incision related - Prolonged localized erythema, stitch granuloma, scarring (rare), or nasal tip ischemia (very rare)

  • General rhinoplasty related - Loss tip definition or symmetry, polly beak deformity or loss of favorable supratip break, inappropriate columellar show, alar-columellar disproportion, crooked nose deformity, or other well-recognized rhinoplasty complications

Long-term outcomes at 10 years or longer are the standards by which rhinoplasty and nasoseptal reconstruction procedures should be judged and evaluated. Most available studies are limited by short follow-up, small numbers of patients, outcomes influenced by the surgeon's experience with a particular approach or technique, variability in intrinsic patient factors, and patient selection. Nevertheless, reviewing the available, albeit imperfect, data on the use alloplasts and the application of autogenous grafts is useful.

Alloplasts

The infection and extrusion rates of synthetic implants are of prime concern regarding their wider nonselective use in rhinoplasty. Most published studies reveal alloplast infection rates of 2-4%. True implant extrusion rates are difficult to ascertain because of variable patient follow-up intervals, patients lost to follow-up, and the lack of substantial long-term studies. On the basis of available studies, implant extrusion rates range from 0% to 9%.

Conrad and Gillman evaluated the use of ePTFE implants in 189 patients undergoing rhinoplasty. ^[23] Follow-up intervals varied from 3 months to 6 years (average, 17.5 mo) with 5 cases (2.6%) of implant removal secondary to infection. Two implants were removed because of chronic inflammation and soft tissue reaction. No cases of implant extrusion, migration, or resorption were reported.

Godin et al reviewed 309 patients who received ePTFE implants for a 10-year period. ^[24] With an average follow-up of 40.4 months (range, 5 mo-10 y), 10 implants (3.2%) were removed secondary to infection.

Niechajev's review of 23 nasal reconstructions using PHDPE nasal implants revealed successful aesthetic outcomes in all patients, with a mean follow-up of 2 years (range, 1-3 y). ^[25] In this study, 2 implant extrusions (9%) were treated with minor revision surgery, and 1 case of implant infection (4%) was treated with antibiotics.

Turegun et al used PHDPE implants in reconstructing the noses of 36 individuals with saddle-nose deformities and reported that no cases required implant removal. ^[26] However, the follow-up in this study was generally short (8-18 mo), and the aesthetic and functional outcomes were poorly defined.

Romo et al used PHDPE nasal implants in 15 saddle-nose reconstructions and noted 1 major complication because of a twisted dorsal implant at 1-year follow-up. Of the 15 patients, 14 (93%) were pleased with their aesthetic outcomes (follow-up duration unknown). Despite attempts at precise contouring of the implant prior to its placement, the investigators noted demarcation of the lateral borders of a number of implants placed on the dorsum.

In another study, Romo et al applied PHDPE implants in 121 cases involving revision rhinoplasty and in 66 platyrrhine noses. ^[27] In most cases, the implant was used to augment the dorsum and reinforce the columella. From a total of 187 cases, 5 implants (2.7%) needed to be removed because of 3 early and 2 delayed implant infections.

Beekhuis' report of 70 patients with various degrees of nasal dorsal saddling who were all treated with rhinoplasty and polyamide mesh placement revealed 3 cases (4%) of implant removal (all because of infection). ^[28]

Autogenous material

In a review article about surgical correction of the saddle-nose deformity, Tardy describes his 20-year experience in using various autogenous grafts in nasal reconstruction with gratifying results and no major complications. ^[29] Infection rates with autogenous cartilage are low, and infections can be successfully treated with antibiotics. Rates of auricular cartilage warping are variable but approximately 4-7%. Cartilage extrusion rates are less than 5%, with most cases of extrusion resolving spontaneously.

Sherris treated 21 patients requiring caudal and dorsal septal reconstruction by using only autogenous material. Material used included septal cartilage; autogenous rib grafts; ethmoid bone; and, in one case, calvarial bone grafts. With an average follow-up of 19.8 months (range, 12-29 mo), no cases of infection, graft extrusion, or warping were noted. He noted one case (5%) of partial (rib) graft exposure, which resolved spontaneously without any sequelae, and one case (5%) in which (calvarial bone) graft resorption in the nasal tip area had been noted at 2-year follow-up. Aesthetic outcomes were "much improved" in 76% of the cases and "improved" in the remaining 24%.

Murakami et al used irradiated rib cartilage to reconstruct 18 saddle-nose deformities. ^[30] With a follow-up of 1-6 years (mean, 2.8 y), no cases of infection, extrusion, or noticeable resorption were noted. One (6%) graft had to be removed secondary to warping, and 2 (11%) displaced caudal struts had to be repositioned under local anesthesia. Long-term evaluation of irradiated cartilage grafts by Welling et al revealed progressive graft resorption with time. ^[20] Animal studies by Donald have also demonstrated the steady resorption of irradiated cartilage with time. ^[31] This resorption may discourage the use of irradiated cartilage in younger patients, in whom long-term resorption may limit the lifespan of the nasal reconstruction.

Adams et al have demonstrated decreased rib cartilage warping rates when the cartilages were carved from central portion rather than peripheral portions of the harvested cartilage. ^[17] Gunter and colleagues significantly reduced their postoperative cartilage warping rates by internally stabilizing rib cartilage grafts by using Kirschner wires (K-wires). ^[32] Toriumi describes minimizing the risk of long-term warping by performing adequate symmetric carving of the graft, by not leaving any perichondrium on the graft, and by dissecting a precise subperiosteal graft insertion pocket. ^[33]

Ozturan et al described the use of an “accordion” technique for preventing costal cartilage warping in saddle-nose repair. In the surgery, on 23 patients with severe saddle-nose deformity, a horizontal transection was made every 2 mm along the length of the costal cartilage graft (on alternate sides) prior to graft implantation. None of the patients experienced postoperative warping. In contrast, seven of 18 patients (39%) with comparable saddle-nose deformity who underwent costal cartilage repair without use of the accordion technique suffered early and/or late postoperative warping. ^[34]

In the study by Gerow et al, the use of rib bone grafts for 16 saddle-nose reconstructions yielded good aesthetic results with no significant complications. ^[19] Some of the cases described had continued good aesthetic results at long-term follow-up (7-10 y). Bone absorption was noted in all cases, but in no cases did the deformities recur.

The future of nasoseptal reconstruction continues to evolve on the basis of long-term results, the introduction of new techniques, and the use of increasingly biocompatible homografts and implants. ^[35] The ideal alloplasts are yet to be found, but the search for new compounds may facilitate the development of an ideal alloplast. Future developments in bioengineering may allow the production of autologous soft tissue products (eg, cartilage). This advancement will eliminate the importance of material as a limiting factor in complicated nasal reconstructions. Until then, the intelligent and creative use of autogenous grafts can allow the surgeon to address an almost limitless array of nasal deformities, including the saddle nose.