Polly Beak Deformity in Rhinoplasty

Polly beak deformity is a complication of rhinoplasty defined by the typical appearance of a dorsal nasal convexity resembling a parrot's beak. ^{[1, 2, 3]} This dosal hump is located in the supratip region of the nose which then "pushes" the tip downward causing under-rotation. It can occur through several mechanisms. If during the intraoperative evaluation of the nose, a surgeon does not recognize the improper tip-supratip relationship that is the hallmark of this deformity, a polly beak occurs. In addition, polly beak deformity may develop because of the inability of a surgeon to precisely predict the ultimate healing of the nose.

See the image below.

In patients, especially those with a thick skin soft tissue envelope, excess scar tissue can form in the supratip. This will produce a similar effect.

Polly beak deformity describes the postoperative deformity associated with fullness in the supratip that leads to a disproportionate relationship between the tip and the supratip. ^[4]

Frequency

The incidence of polly beak deformity is not known; however, it is one of the more common complications of rhinoplasty. One study showed that 64% of patients presenting for revision rhinoplasty had a polly beak deformity. A retrospective study of 28 ethnic patients who underwent revision rhinoplasty found that polly beak deformity and persistent bulbous tip were among the most common indications for revision. ^[5]

Two general categories of a polly beak deformity are described. Each can result as a consequence of 1 or more conditions.

• Cartilaginous polly beak

  • Overresection of the nasal bones

  • Underresection of the cartilaginous dorsum

  • Overresection of the lower lateral cartilages (leading to loss in tip support)

• Soft-tissue polly beak

  • Poor redraping of inelastic nasal skin

  • Excessive skin thickness at the nasal tip after reduction rhinoplasty

  • Inadequate trimming of the vestibular mucosa after large reductions

  • Soft tissue (scar) excess in the region of the supratip

During surgery, excess edema often obscures the deformity. After surgery, scar tissue can replace edema of the supratip.

Patients with a polly beak deformity are generally dissatisfied with the birdlike appearance of their nose. Many patients report that their nose was massively swollen after surgery and that they noticed the deformity after the swelling resolved.

In the case of loss of tip support, patients notice that the nose initially looks fine but that it evolves into a deformed profile. A clear understanding of the support mechanisms for the nasal tip, maintaining them, and reconstructing disrupted elements of tip support are paramount to preventing the eventual settling of the tip that occurs when these mechanisms are disturbed. ^[6]

Most of the healing from a rhinoplasty procedure takes a full year to complete, though the nose continues to change over a lifetime. In general, the outcome should not be critically assessed until a year after surgery. Delaying treatment of a polly beak deformity for a year is prudent; this delay allows the normal healing process to occur. A delay or more than a year may be necessary in patients with thick skin.

Secondary or revision rhinoplasty is indicated in patients who have an obvious deformity that will not heal in a satisfactory manner.

Surgery is indicated in patients who have a soft-tissue polly beak that is unresponsive to steroid injection.

The supratip is defined as an area of thick skin above the nasal tip (see the images below). The cartilaginous dorsal septum composed of quadrangular cartilage supports the supratip.

The nasal tip is composed of lower lateral cartilages. The most anterior point of the nasal tip, eg, the junction of the lateral and intermediate crus, is known as the tip-defining point.

Understanding the normal relationship of the tip and the supratip region is paramount to predict the outcome of rhinoplasty. The nose may be divided into horizontal thirds, with the upper one third composed of bone and the lower two thirds composed of cartilage (see the image below). The thickness of skin varies according to the region of the nose.

In the normal nose, the tip-defining point should be approximately 6-10 mm anterior to the dorsal septum (eg, supratip) to have a supratip break. The skin in the area of the supratip is thick; take this into account when aligning the patient's profile. In men, a straight-line profile might be preferred. A straight-line profile helps minimize a height discrepancy between the tip and the supratip.

A polly beak deformity appears unnatural and occurs when the supratip region leads the tip. A clear understanding of the nasal-tip support mechanisms is needed to predict the dynamic changes that occur during the rhinoplasty operation. Major and minor tip support mechanisms are listed below.

• Major

  • Size, shape, and resiliency of the lower lateral cartilages

  • Relationship of the medial crural feet to the cartilaginous septum

  • Attachment of the caudal margin of the upper lateral cartilages to the cephalad border of the lower lateral cartilages

• Minor

  • Interdomal ligament

  • Cartilaginous dorsum (septum)

  • Relationship of the lower lateral crura to the pyriform aperture and the sesamoid cartilages

  • Maxillary crest (nasal spine)

  • Membranous septum

  • Attachment of the alar cartilages to the overlying skin soft tissue envelope

Correction of a polly beak deformity is contraindicated in patients with clinically significant medical problems that may preclude safe surgery or in patients in whom psychological factors make further surgery unwise. Take care when reducing the nasal dorsum in a patient with a septal perforation.