Polly Beak Deformity in Rhinoplasty 

Updated: Mar 02, 2016
Author: Henry Daniel Sandel, IV, MD; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

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.

Supratip (arrow) and tip-defining point (cross). Supratip (arrow) and tip-defining point (cross).

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.

Problem

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]

Epidemiology

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]

Etiology

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.

Presentation

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.

Indications

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.

Relevant Anatomy

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.

Supratip (arrow) and tip-defining point (cross). Supratip (arrow) and tip-defining point (cross).
The supratip region is an area of thick skin. The supratip region is an area of thick skin.

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.

The nose can be divided into horizontal thirds; th The nose can be divided into horizontal thirds; the upper third being bony and the lower two thirds being cartilaginous.

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

Contraindications

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.

 

Workup

Other Tests

See the list below:

  • Perform photographic analysis of the face and nose before repairing the deformity.

    • Standard photographs of the face for rhinoplasty include frontal, submental, lateral, and oblique views. Obtain the lateral and oblique view from both sides.

    • Align the patient's head with the Frankfurt horizontal plane when taking photographs of all views except with the view of the submental vertex.

    • Assess dynamic muscular input from the depressor septi nasi muscle with a lateral smiling view. The action of this muscle may yield a dynamic nasal-tip ptosis.

  • Video or digital computer imaging may be helpful in discussing the procedure and its goals with the patient. The images can be adjusted to illustrate the potential changes.

  • Palpate the nose.

    • Tip support is determined by depressing the domes of the lower lateral cartilages toward the posterior septal angle. The degree of depression and recoil are assessed.

    • Supratip scar is assessed by palpation. Palpation of the nasal dorsum distinguishes cartilaginous excess from scar tissue excess.

 

Treatment

Medical Therapy

Medical treatment is possible only in the early stages of soft-tissue polly beak.

Steroid injections can be administered to decrease edema and ultimately the amount of scar tissue that forms in the dead space of the supratip region. These injections can be given prophylactically in patients at increased risk of this deformity (eg, those with thick nasal skin, poor skin elasticity, large nasal reductions) or as treatment for a developing polly beak. Injections must be deep to the dermis to avoid changes in the dermis and epidermis (eg, hypopigmentation, atrophy). Triamcinolone acetonide 10 mg/mL (0.1-0.5 mL) can be injected into the area. The injection should not be administered more often than once every 3-4 weeks. Overtreatment may result in atrophy that may produce saddle-nose deformity or irregular skin changes. Diminishing returns are noted with repeated injections.

Surgical Therapy

The profile is aligned by balancing dorsal reduction and augmentation. The importance of preoperative nasal analysis cannot be stressed enough. This thorough assessment helps the surgeon identify problem areas, consider solutions, and mentally perform the operation before embarking on the actual procedure.

For the patient with overreduced nasal bones, the nose may be balanced by using a graft placed in the region of the radix to properly reduce the cartilaginous septum.

For the underresected cartilaginous dorsum, resection is recommended, with careful intraoperative assessment of the relationship to the tip. Tissue edema should be minimal to accurately judge this relationship. For the external rhinoplasty approach, redrape the skin-soft tissue envelope before evaluating the profile. In addition, account for the degree of tip settling (1-2 mm) that may occur after surgery.

Fibrin glue may be used prophylactically in patients who are at high risk for a postoperative polly beak deformity. If amount of dead space between the skin and its underlying cartilaginous framework is substantial, fibrin glue can be used to promote adherence. This method helps prevent the formation of excessive scar tissue and helps improve definition of the nasal tip. As an alternative, in patients with thick skin, placement of an absorbable suture from the dermis to the deep tissues (cartilaginous dorsum of the supratip) can make the skin redrape appropriately. Tying of this suture may need to be tried several times before an appropriate position is achieved.

Preoperative Details

Photographic analysis before surgery involves evaluating the lateral view in particular. Especially focus on the area of the tip and supratip. Evaluate the relationship of the tip and supratip compared with the entire nose to accurately diagnose the problem. Physical examination complements the photographic analysis and enables accurate surgical planning.

Intraoperative Details

Palpate and observe the patient's profile (lateral view) after incremental reduction or augmentation is performed. If the amount of dead space is substantial on redraping, use of fibrin glue may be useful.

Postoperative Details

Careful attention to taping the nasal dorsum is critical. To lessen the degree of tissue edema (and eventual formation of scar tissue) in patients with thick skin, a material such as nonadhesive wound dressing (Telfa; Kendall, Mansfield, MA) or absorbable gelatin sponge (Gelfoam; Pfizer, New York, NY) may be placed in the area of the supratip beneath the tape and cast to provide additional pressure in this region.

Follow-up

Remove the cast in 1 week. Make a preliminary assessment of the outcome after the cast is removed.

If edema is substantial, tape should be reapplied, and the patient should return in 1-2 weeks. Some patients may be candidates for steroid injections at this time. If a patient continues to have excessive supratip edema and scar tissue, steroid injection may be performed again at 4-6 weeks postoperatively.

Complications

Excision of scar tissue in the supratip region may lead to thin atrophic skin and tissue loss. In general, full-thickness skin loss occurs by operating in the improper plane and by performing overly aggressive resection that transgresses the dermis. Blindness is reported as a complication of steroid injection in the region of the nasion after septorhinoplasty. The patient had immediate unilateral blindness. Proximity to the orbit might be the reason for the central retinal embolus of Depo-Medrol. Blindness resulting from injection into the supratip region is not reported.

Overuse of steroid injections can result in atrophy at the site of injection. This atrophy can lead to a depression of the supratip region resulting in a saddle-nose deformity. Other skin changes, including subdermal atrophy, depigmentation, telangiectasia formation, necrosis, and ulceration, can occur.

Outcome and Prognosis

The outcome is best assessed at the 1-year follow-up visit. In patients with thick skin, a period longer than this may be needed.

Future and Controversies

Arslan et al described a rhinoplasty flap technique meant to avoid the development of polly beak deformity from overresection of the caudal dorsum. Such overresection creates a gap between the septum and the tip of the lower lateral cartilages, causing fullness of the supratip area as soft tissue fills in the space. To reduce the gap, 42 patients were treated with a reverse nasal superficial musculoaponeurotic system (SMAS) ̶ perichondrium flap. Over a follow-up period of 3-18 months, no complications (eg, infection, extended edema, or excessive bleeding) were reported, although two patients did undergo minor surgical revisions. Arslan and colleagues cautioned that the flap should be used cautiously or not at all in patients with thin skin. They also noted that their report did not include long-term results and that larger studies are needed to better determine the technique’s advantages and disadvantages.[4]