Polly Beak Deformity in Rhinoplasty Treatment & Management

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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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]

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