347
23 Open Technique Rhinoplasty
e
c
d
Fig 23.52 (continued)
348
A. Di Giuseppe
References
1. Johnson CM, Toriumi DM (1990) Open structure rhi-
noplasty. WB Saunders Co, Philadelphia
2. Micheli–Pellegrini V (2004) Corporeita’ del Naso,
Firenze
3. Zaoli G (1992) Rinoplastica estetica. Piccin, Padova
4. Monasterio O (1994) Rhinoplasty. WB Saunders Co,
Philadelphia
5. Peck GC (1990) Rhinoplasty, 2nd edn. JB Lippincott
Co, Philadelphia
6. Gruber RP, Peck GC (1993) Rhinoplasty: state of the
art. Mosby Year Book, St. Louis
Fig. 23.53 One month postoperative
349
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_24, © Springer-Verlag Berlin Heidelberg 2013
24
24.1
Historical Background
In most cases, posttrauma deformations of the
nose are deviations of the nasal pyramid, impac-
tion of the nose, or “bosses.” The tip of the nose
is not concerned by posttrauma deformations. In
order to perform the surgical corrections of these
osseous deformations, it appeared to us that it
was possible to access to the skeleton of the nose
by the same route than in the other fractures of
the face. The upper buccal sulcus approach gives
a good access to the anterior nasal spine, to the
nasal septum, and to the frontal processes of the
maxilla under direct vision.
The transoral route has already been used to
carry out parts of the rhinoplasty. Aubry and
Senechal [ 1 ] performed the lateral osteotomies
using two small oral incisions in order to place
the osteotome in better position. Wayhoff [ 2 ]
described a double approach for the rhinoplasty:
endonasal to approach the septum in Cottle’s
manner [ 3 ] and cutaneous or sometimes oral to
perform the lateral osteotomies.
Aiach [ 4 ] envisaged the possibility of an
oral approach to the septum combined to the
nasal approach. Kim and Kim described a com-
bined approach (oral and nasal) using an endo-
scope [ 5 ] .
The dorsal hump and nasal deviation resulting
from a trauma can be successfully treated from a
buccal approach alone [ 6, 7 ] .
24.2
Technique
This technique is easier to describe showing a
cadaveric dissection (Fig. 24.1 ) that allows a bet-
ter vision of the surgery. The incision is an upper
buccal sulcus incision from the right canine to the
left one. A subperiosteal dissection of the ante-
rior nasal spine and the premaxillary part of the
maxillas is performed, allowing the approach of
the pyriform fossa (Fig. 24.2 ). This primary part
The Upper Buccal Sulcus Approach
in Posttrauma Rhinoplasty
Christian Vacher
C. Vacher , M.D., Ph.D.
Publique Hôpitaux de Paris , Hôpital Beaujon,
Université Paris-Diderot (Paris VII) , Paris , France
Service de Chirurgie Maxillo-Faciale ,
Hôpital Beaujon , 100 Boulevard du Général Leclerc ,
92110 Clichy , France
e-mail: christian.vacher@bjn.aphp.fr
Fig. 24.1 Fresh cadaver dissection. Preoperative
350
C. Vacher
of the technique is the same that is used at the
beginning of a Le Fort 1 osteotomy.
After a subperichondral dissection of the sep-
tum, a resection of a small strip of the nasal sep-
tum at its superior edge is performed (Figs. 24.3 ,
24.4 , and 24.5 ) just below the nasal dorsum.
After a subperiosteal dissection of the lateral
borders of the pyriform foramen (frontal pro-
cesses of the maxillas), the lateral osteotomies
are performed under direct vision (Fig. 24.6 ).
The whole nasal pyramid is then impacted and
repositioned to correct the dorsal hump and any
deviation (Figs. 24.7 , 24.8 , 24.9 , 24.10 , and
24.11 ). This technique of impaction has been
described by Gola via endonasal incisions [ 8 ] .
A mesh is placed in each side of the nasal
cavity for 48 h to replace the nasal mucosa of
the septum that has been elevated without any
nasal incision (Fig. 24.12 ). The upper buccal
sulcus incision is sutured using absorbable
sutures. A contention is placed on the dorsum
for 1 week.
Fig. 24.2 Fresh cadaver
dissection. The anterior nasal
spine and the lateral borders of
the pyriform foramen have been
dissected. Subchondrial
dissection of the nasal septum
Fig. 24.3 Fresh cadaver
dissection. Resection of a
small strip of the nasal
septum at its superior edge
351
24 The Upper Buccal Sulcus Approach in Posttrauma Rhinoplasty
24.3
Indications
This technique can be used in most cases in post-
trauma deviations of the nose or twisted nose
(Figs. 24.13 , 24.14 and 24.15 ). In posttrauma
twisted noses, the combination of internal and exter-
nal deformities can result in nasal valvular narrow-
ing. Trauma is the second leading cause of valve
dysfunction in most series [ 9, 10 ] . Classic rhino-
plasties can improve the nasal valve obstruction and
constitute the fi rst leading cause of valve dysfunc-
tion. Grymer estimated that rhinoplasty decreases
the cross-sectional area of the nasal valve by 25%
[ 10, 11 ] . Sheen demonstrated that 75–95% of
patients had reduction of the nasal vestibule after
Fig. 24.4 Subchondrial dissection of the nasal septum
a
b
Fig. 24.6 ( a ) Fresh cadaver dissection. After resection of
the superior edge of the septum and the lateral osteoto-
mies the nasal dorsum is mobile on the left. ( b ) The nasal
dorsum is also mobile on on the right allowing correction
of all nasal deviations
Fig. 24.7 Fresh cadaver dissection. Lateral osteotomy
under direct vision
Fig. 24.5 Right nasal cavity. Resection of a small strip of
the nasal septum
352
C. Vacher
a
b
Fig. 24.8 ( a ) Fresh cadaver dissection. If necessary the nasal dorsum can be impacted. ( b ) Result of the nasal dorsum
impaction
a
b
Fig. 24.10 ( a ) Fresh cadaver dissection. After resection of the nasal skin, the location of the lateral osteotomies is
visible. Right aspect. ( b ) Left aspect
Fig. 24.9 The impaction of the nose has been described by Gola via endonasal incisions
353
24 The Upper Buccal Sulcus Approach in Posttrauma Rhinoplasty
Fig. 24.11 Fresh cadaver dissection. After resection of
the nasal skin, demonstration of the impaction of the nasal
dorsum allowing correction of nasal deviation or hump
reduction
Fig. 24.12 Fresh cadaver dissection. Opening of the
nasal fossa showing the integrity of the nasal mucosa
a
b
Fig. 24.13 ( a ) Preoperative showing deviation to the right 1 year after trauma. ( b ) Postoperative 3 months after rhino-
plasty via transoral route
a
b
Fig. 24.14 ( a ) Preoperative showing deviation to the right 6 months after trauma. ( b ) Postoperative 3 months after
rhinoplasty via transoral route
354
C. Vacher
a transnasal rhinoplasty [ 10, 12 ] . In some cases
when patients have not been operated from impor-
tant fractures of the nose before osseous consoli-
dation, we used this technique of rhinoplasty via
transoral route to respect the nasal mucosa in the
nasal valve, as an early technique of correction of
nose deformities (Figs. 24.15 and 24.16 ).
a
b
Fig. 24.15 ( a ) Preoperative showing deviation to the right 6 months after trauma. ( b ) Postoperative 3 months after rhi-
noplasty via transoral route
a
b
Fig. 24.16 ( a ) Preoperative showing deviation to the left
2 weeks after trauma. The fracture of the nose has not
been operated in emergency because the patient had a
polytrauma with severe abdominal and orthopedic lesions.
( b ) Postoperative 3 weeks after early posttrauma rhino-
plasty via transoral route which has been performed
3 weeks after trauma because of the severity of the
deformation
355
24 The Upper Buccal Sulcus Approach in Posttrauma Rhinoplasty
24.4
Advantages of the Upper
Buccal Sulcus Approach
This transoral route avoids nasal scarring and
scar retraction of the nasal mucosa that can be
observed after internal nasal approaches. The
upper buccal sulcus approach respects the nasal
valve. With this technique, the lateral osteotomies
are possible to perform under direct vision.
24.5
Disadvantages of the Upper
Buccal Sulcus Approach
With this approach, surgery of the alar cartilage
is impossible. The upper buccal sulcus approach
can be responsible for temporary loss of sensibil-
ity of the upper lip.
References
1. Aubry M, Sénéchal G (1960) L’incision endo-buccale
vestibulaire dans la chirurgie de la pyramide nasale.
Ann Otol Rhinol Laryngol 77:740–744
2. Wayoff M (1969) Quelques vérités premières sur
l’anatomie et la physiologie de la cavité nasale. J Fr
Otorhinolaryngol 18(5):273–275
3. Cottle MH, Loring RM, Fischer GG, Gaynon IE (1958)
The maxilla-premaxilla approach to extensive nasal
septum surgery. Arch Otolaryngol 68(3):301–313
4. Aiach G (1993) Atlas de Rhinoplastie et de la Voie
d’Abord Externe. Masson, Paris
5. Kim JT, Kim ST (2001) Endoscopically assisted,
intraorally approached corrective rhinoplasty. Plast
Reconstr Surg 108(1):199–205
6. Vacher C, Accioli J, Lezy JP (2002) Surgical anatomy
of the nose in the elderly: value of conservative rhino-
plasty by the transoral route. Surg Radiol Anat 24(3–4):
140–146
7. Vacher C, Accioli de Vasconcellos JJ, Britto JA (2003)
The upper buccal sulcus approach, an alternative for
post-trauma rhinoplasty. Br J Plast Surg 56(3):218–223
8. Gola R, Nerini A, Laurent-Fyon C, Waller PY (1989)
Rhinoplastie conservatrice de l’auvent nasal. Ann
Chir Plast Esthet 34:465–475
9. Elwany S, Thabet H (1996) Obstruction of the nasal
valve. J Laryngol Otol 110(3):221–224
10. Schlosser RJ, Park SS (1999) Functional nasal surgery.
Otolaryngol Clin North Am 32(1):37–51
11. Grymer LF (1995) Reduction rhinoplasty and nasal
patency: change in the cross-sectional area of the nose
evaluated by acoustic rhinometry. Laryngoscope
105(4 Pt 1):429–431
12. Sheen JH (1984) Spreader graft: a method of recon-
structing the roof of the middle nasal vault following
rhinoplasty. Plast Reconstr Surg 73(2):230–239
357
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_25, © Springer-Verlag Berlin Heidelberg 2013
25
25.1
Introduction
The nose is the most distinctive part of the human
face, and it gives it a special mark, its distinction,
and beauty. Owing to all this, the nose has been a
body part which, if cut, ruined one’s beauty
permanently.
The ideal of a beautiful face known today has
been postulated by the works of Leonardo da
Vinci (1452–1519) and Albrecht Durer (1471–
1528). According to this concept, a harmonious
and beautiful face of a human is divided into
three equal horizontal and fi ve equal vertical
parts; needless to say, this is strictly de fi ned for
white race, that is, the leptorrhine nose. This con-
cept of the nose is more appropriate for an
aesthetic approach, because regarding health the
function comes fi rst, aesthetics second. If, after a
surgery, we gain a nose that is beautiful, but not
functional, the results are unacceptable, as well
as when a functional nose is followed by a bad
aesthetic outcome. Both outcomes result in per-
manent emotional sufferings of the patients. It
would be ideal to combine good functional results
with a good aesthetic outcome.
A speci fi c characteristic of rhinoplasty lies in
its dual approach, that is, it should meet the
requirements of both aesthetics and function of
the nose or its maintenance if suffering. It is espe-
cially important to approach a detailed analysis
of nasal and facial con fi guration and the need to
harmonize in order to achieve the best possible
results. Rhinoplasties are a speci fi c surgical pro-
cedure because their indications are not only doc-
tor’s decision but, in most cases, patients’
themselves. During the assessment of patients, it
is necessary to pay close attention to their charac-
ter traits and possible personality disorders lead-
ing to an inevitably unsatis fi ed patient regardless
of successful outcome [ 1 ] . It is proven that even
in patients without personality disorders a rhino-
plasty leads to basic personality changes [ 2– 4 ] .
Nasal hump is the most common type of nasal
deformity resulting in aesthetic surgery in patients
whose breathing function is satisfactory [ 5, 6 ] . In
this situation, a surgeon has to adjust the size of
the nose to the size of the face. Every patient
should be warned that nose reduction with regu-
lar septum leads to the reduction of air fl ow and
the increase of air resistance through nose [ 7, 8 ] .
Rhinoplasty: Open Techniques
Vladimir Kljajic , Jovan Radmanovic , Ljiljana Vlaski ,
and Slobodan Savovic
V. Kljajic , M.D. ()
ENT Clinic, Clinical Center of Vojvodina ,
Hajduk Veljkova 1 , Novi Sad , Serbia
e-mail: kljaja@eunet.rs
J. Radmanovic , M.D.
ENT Clinic, Clinical Center of Vojvodina ,
Hajduk Veljkova 1 , Novi Sad , Serbia
ENT Department , Hospital of Sremska Mitrovica ,
Sremska Mitrovica , Serbia
e-mail: niki05@open.telekom.rs
L. Vlaski , M.D. • S. Savovic , M.D.
Medical Faculty , ENT Clinic,
Clinical Center of Vojvodina ,
Hajduk Veljkova 1 , Novi Sad , Serbia
e-mail: vlaskiLj@eunet.rs ; savovics@yahoo.com
358
V. Kljajic et al.
On the basis of incisions that are made in order
to lift soft nasal tissue and showing the skeleton of
the nasal pyramid as well as the septum, all surgi-
cal techniques can be divided into open and close
ones. In close techniques, incisions are inside the
nasal cavity and are not visible whereas in the
open ones the fi rst incision on columella skin.
All surgical techniques have their advantages
and downsides. Recovery period is shorter in
close techniques; there are no visible scars. Their
downsides are poor visibility of the surgical fi eld
and inability to correct nasal pyramid deformi-
ties. In open techniques, the recovery period is
longer and scars on columella are visible. Their
advantage is the possibility of complete recon-
struction of the nasal pyramid; it is possible to
insert grafts and their precise fi xation to cartilage
tissue and soft structures of nasal pyramids. In
cases of failure, open techniques are a must.
25.2
History
Roe [ 9 ] and Weir [ 10 ] published their papers on
curing a lordotic nose at the end of the 1980s and
the beginning of the 1990s of the nineteenth cen-
tury. Innovations in solving of a deformed nose
pyramid were introduced by Joseph at the end of
the nineteenth century. He even introduced new
instruments in doctors’ practice, some of which
are still used. Joseph’s concept of the nose sur-
gery spread fast on the United States owing to
Aufricht, Sa fi ano, and Foman. The last one took
merit for Cottle and Goldman’s education who
are considered the founders of the contemporary
concept of septoplasty, and, consequently, they
can be considered founders of close techniques.
At the beginning of the twentieth century,
Freer and Killian introduced nasal septum sub-
mucous resection. It was thought that the removal
of the cartilage and bone part of nasal septum
eliminated mechanical breathing malfunction.
This attitude held true until 1947, when Cottle
introduced hemitrans fi xion incision and the con-
cept of four tunnels. He pointed out the
signi fi cance of structure nasal pyramid statics
preservation [ 11 ] . He was ardently for close sur-
gical techniques.
Rethi is considered the founder of open surgi-
cal techniques, and he used nasal tip solving for
this approach. Sercer contributed further popular-
ization of open techniques in former Yugoslav
region, and he introduced the term of nasal deco-
rtication along with columella incision imple-
menting [ 12 ] . During Padovan’s stay in the USA
in 1974, popularization of open techniques
spread in this country.
25.3
Surgery Indications
The indication for open techniques implementa-
tion is numerous one. If one counts into consider-
ation curing of certain types of nasal pyramid
deformities, it is clear that open techniques solve
all types of deformities. Open techniques solve
only a bulbous nose, a large nose (rhinomegaly),
deformities that are a consequence of hard palate
fi ssure, a long nose, and, needless to say, disorders
of shape and function after rhinoplasties. Nasal
valve insuf fi ciencies represent a special problem,
both inborn and gain during lifetime. These tech-
niques enable to in fi x all kinds of grafts.
25.4
Incisions
All incisions in nose decortication can be divided
into columella incisions and incisions of nose
vestibule. Columella incision is the key element
in performing open surgeries. This incision is, at
the same time, a disadvantage of this technique.
When a cut is done in the columella region, a
more or less visible scar stays, depending on indi-
vidual characteristics, and some populations can
be more prone to visible scar occurrence [ 13 ] .
This incision is the reason why many surgeons
primarily tend to do close rhinoplasty. Surgeons
should be particularly cautious when they have
scar-susceptible patients because this can result
in a nasty complication after this kind of surgery.
Due to this reason, it is necessary to ask a patient
if they have any body scars after another surgery
or an injury, to see the size of the scar and on this
basis foresee the risks of a hypertrophic columel-
lar scar occurrence.
359
25 Rhinoplasty: Open Techniques
Columella incisions can be divided into:
1. “V” incisions (Fig. 25.1 )
2. Modi fi ed “W” incisions
3. Stair-shaped incision “¯|_” (Fig. 25.2 )
According to the region where columella incision is
done, they are divided into high (in the upper third
of columella), medium (in the mean third of colu-
mella), and low (in the lower third of columella).
Besides incisions, it is necessary to do both-
sided precartilaginous incisions. These incisions
enable us to lift nasal soft tissue completely. If
necessary, it is possible to do both-sided incisions
on the basis of nasal wings in order to diminish
the size of nostrils.
25.5
Surgical Procedure
The surgery can be done in local or total anesthe-
sia. Our recommendation is to fully or totally
anesthetize patients undergoing bone nose struc-
ture correction.
Nasal tip corrections or in fi xing certain
implants can be done in local anesthesia in the
course of which adrenalin solution and 2%
Cystocain in fi ltration is done. In fi ltration is done
with a needle used for subcutaneous insulin
administration. Adrenalin is dissolved in ratio
1:200,000. Columella region is anesthetized fi rst,
and then nasal septum and cartilaginous parts of
nasal pyramid.
It is common consensus that all rhinoplasties
should be done under total anesthesia in con-
trolled hypotension, fi rst because of the patients’
comfort and second because it enables surgeons
to be more relaxed while performing surgery.
First, stair-shaped skin incision is done and
then both-sided precartilaginous incision with a
Bard-Parker 15 knife. Afterward, using fi ne scis-
sors with sharp ends, the skin and underskin to
the alar cartilage are lifted. Along the anterior
edge of medial branches of alar cartilages, soft
tissues are lifted together with skin. When the
whole columella is lifted to the passage of lateral
to medial crus, both alar cartilages, soft tissue
lifting is continued along perichondrium itself. A
rhinosurgeon has to be particularly cautious at
this point. If a larger skin part is removed from
subcutaneous tissue, there is a danger of necrosis
in the postsurgical period. Soft tissue lifting con-
tinues directly below above the pericondrium
until the K region, and further periosteum lifting
(Fig. 25.3 ).
When the whole insight into nasal pyramid is
skeleton achieved, the surgeon approaches the
nasal septum from above. The caudal septum can
be exposed bilaterally down to the maxillary
spine and crest if needed (Fig. 25.4 ).
Necessary procedures are done on the nasal
septum in regard to its aligning and satisfactory
shaping. A rhinosurgeon has to be aware of the
fact that the nasal septum is the carrier of the
whole cartilaginous part of the nose, that is, strut
of the nose, according to some authors. This
Fig. 25.1 “V” columellar incision
Fig. 25.2 “Stair-shaped” columellar incision
360
V. Kljajic et al.
should be kept in mind because if nasal resection
is overdone or too little septal cartilage is left in
the region of nasal dorsum, nasal tip “drops” over
the time, and the pro fi le line is lost. In case of a
big nasal septum deformity, and consequently it
is not possible to get a satisfactory result by sur-
gical shaping, it is necessary to form an L pro fi le
to carry the shape of nasal pyramid, and to thin
out the other parts of the nasal pyramid and form
by the medical thread Vicryl 6-0 mosaic that is
fl at and to implant it into the region below L
pro fi le (Fig. 25.5 ).
While connecting the parts of cartilage, it is
necessary for rhinosurgeon to comply with the
rules according to which parts of cartilage are
sown to each other according to type. This way of
connecting cartilage parts to each other prevents
moving of fragments and postsurgical heavy nose
breathing. If a larger part of nasal septum without
cartilage or bones occurs after shaping, nasal sep-
tum perforation may occur. If located in posterior
parts of the nose, perforation usually stays asymp-
tomatic. If they are in anterior parts, notably in
the cartilage part, breathing problems occur as
well as constant collecting and drying of secre-
tion at the edges of perforation. In lesser perfora-
tions, nose whistling occurs, and it is both by the
patients and people around them.
After reconstruction is done and the nasal
septum shaped, triangular and alar cartilages are
corrected as well as necessary osteotomies.
Osteotomies are divided into medial, parame-
dial, and lateral. They all serve for shaping the
bone part of nasal pyramids to an ideal size.
When a bone-cartilaginous hump is removed, it
is recommended to place spreader grafts on both
sides that are supposed to increase the volume
of the nose and prevent creating a very narrow
nose dorsum. These grafts are usually made
from septal cartilage, although rib cartilage and
the cartilage of the ear lobe cavum (cavum con-
chae) can be used. Spreader grafts should be
20–25 cm long, 3–4 mm high, and 2–3 mm wide
Fig. 25.3 After soft nose structure lifting and the visible
skeleton of the nasal pyramid
Fig. 25.4 Alar cartilages with the visible part of the cau-
dal part of nasal septum
Fig. 25.5 Forming L pro fi le carrying the nose statics
with reconstruction of the remaining part of the nasal sep-
tum with the help of connected cartilage parts
361
25 Rhinoplasty: Open Techniques
(Figs. 25.6 and 25.7 ). When fi xed, it is recom-
mended to be put in an appropriate position and
then fi xed with needles for subcutaneous medi-
cine administration, and then fi xed onto triangu-
lar cartilage and nasal septum by using the
thread Vicryl 6-0 (Fig. 25.8 ).
The most critical region is the nose valve. The
nose valve is the region of the smallest surface
with minimal diameter of the nose and at the
same time the region with the greatest air fl ow
resistance. When this region is too small, breath-
ing dif fi culties occur. The unique advantage of
open techniques in comparison to the close ones
is that it is possible to correct bone and cartilagi-
nous skeleton of the nasal pyramid under eye
control. It is very important in cases of inborn
deformities or alar cartilage weakness.
25.6
Problems with Nose Tip
To entirely change and to shape the nose tip is
possible during open techniques. Nose tip aug-
mentation, nose tip lifting, narrowing, and shap-
ing are performed depending on the kind and the
degree of deformity. Columella can be narrowed,
shortened, and lengthened in some cases, depend-
ing on the need. If there is need, a cartilaginous
columellar strut can be implanted, a tip graft. If
nose projection has to be corrected, a shield graft
is implanted by using Vicryl 6-0 to fi x to alar car-
tilage (Fig. 25.9 ).
If the nose tip is too wide or torn apart, it is
necessary to perform a caudal part resection of
a
b
Fig. 25.6 ( a )
Situation before
putting spreader
grafts. ( b ) Position
of spreader grafts
Fig. 25.7 Spreader grafts fi xation
Fig. 25.8 Fixed spreader grafts
362
V. Kljajic et al.
the lateral branches of alar cartilages, and then,
alar cartilages should be brought together by
using the Vicryl 6-0 or Prolene 6-0 sutures in the
dome region.
25.7
The Nasal Valve Problem
Due to the weakening of the alar cartilages, aspira-
tion of nasal wings may appear, and these patients
complain about having dif fi culties in breathing.
This is also common with patients who have
undergone a more extensive resection of lateral
branches in order to narrow their nose tips, and
rarely because of hereditary underdevelopment of
alar cartilage’s lateral branches (Fig. 25.10 ). This
problem is best detected by applying Cottle’s
maneuver. The cause of the problem in fl uences
the choice of the solution. If the cause of the aspi-
ration of nasal wings lies in the concave shape of
the lateral branches of alar cartilages, the solution
is to prepare them, cut, and rotate so that the left
branch is placed on the right side and the left one
on the right side (Figs. 25.11 and 25.12 ).
In case there is a problem caused by excessive
resection of alar cartilages or their weakness, it is
also possible to use a part of the nasal septum
cartilage as a support for the lateral crus of the
alar cartilage (lateral crural strut graft) which is
fi xed by using the Vicryl 0–6 suture. Another
option is to use a cartilage graft in order to thicken
the wall in the place of the most prominent col-
lapse (batten graft). In the case of shortage of
material due to more serious deformities or previ-
ous procedures, it is necessary to use other built-
in materials.
25.8
Grafting Materials
In cases of grafting materials de fi ciency as a
result of more complicated deformities or former
surgeries, it is necessary to use other grafting
materials.
Grafting materials are used during revision
surgeries, although they can be used during pri-
mary procedures. The most used are cartilage,
fasciae, and bone implants, while arti fi cial mate-
rials are very rarely used. The risks of using graft-
ing materials is their dislodging and/or even
rejection. Materials can be sorted in the follow-
ing groups:
Fig. 25.9 Shield graft and tip implant
Fig. 25.10 Underdeveloped lateral branch of alar
cartilage
363
25 Rhinoplasty: Open Techniques
1. Autografts (autogeneic or autologous materials)
2. Homografts (allogeneics or homologous
materials)
3. Heterografts (xenografts or xenogeneic)
4. Synthetic materials (implants or allopathic
materials)
Autografts are materials that are used in the same
person. They are just moved from one place to
another. Homografts are tissues that are used
from one person, it is usually a cadaver, and they
are transplanted on another person. Heterografts
are materials that are taken from other organisms
and are grafted and are implanted in the patient.
Synthetic materials are manufactured in factories;
according to some authors, they can be consid-
ered not just grafts but implants as well.
It would be ideal to use materials originating
from the nose itself (nasal cartilage and bone).
Nasal cartilage can be used as a homogenous
material with the purpose of ensuring stability of
the tip of the nose or nasal dorsum, or as grafts in
order to improve breathing in case of nose valve
insuf fi ciency (spreader grafts). Cartilage can be
also used crushed for the better effect. Namely,
when a perichondrial cartilage is crushed, we get
ideal material for covering parts of the bone which
have been cut out. In time the cartilage gets
resorbed, and it turns into a fi brous tissue. In this
way, we create slight shifts between the cut sec-
tions of nasal bones and forehead nasal region. In
order to achieve a nicer construction of the nose
which is operated on, some authors suggest using
fasciae, especially fascia lata [ 14 ] . Combining
crushed cartilage with fascia lata ensures good
augmentation and construction of the nasal pyra-
mid [ 15 ] . Besides the cartilage of the nose itself, it
is also possible to use the cartilage found in ear
lobes and ribs. Boccieri and Marano [ 16 ] prefers
the use of the ear lobe cavum cartilage because of
its easy accessibility, and using the right modeling,
it can be easily used to repair nose cartilage
de fi ciencies. Karen et al. [ 17 ] use a composite graft
of the ear lobe in the process of dealing with nasal
vestibular stenosis. Acarturk S et al. [ 18 ] suggests
order in using built-in materials with patients who
undergo a revising surgical procedure in order to
Fig. 25.11 Rotation of both lateral crus of alar cartilages
Fig. 25.12 Rotated lateral wing of an alar cartilage with
batten graft
364
V. Kljajic et al.
improve breathing function of the nose or appear-
ance of the nasal pyramid in case of the lack of
reconstructive materials. In the fi rst place he puts
the use of the nose cartilage, then cartilage of the
ear lobe cavum, bone graft from crista iliaca, and
fi nally irradiated rib cartilage. Huizing and de
Groot [ 19 ] suggests the use of allogeneic material
if there is the appropriate tissue bank and in case
all the sterilization requirements have been met as
well as if there is no chance of transferring any
bacterial, viral, or prion infection. He prefers
allogeneic material in case of the nose cartilage
and structural de fi ciency since it is highly avoided
to create any scars in the donor section. Tosun
et al. [ 20 ] states that in case of performing a sec-
ondary operation with the tissue de fi ciency, it is
best to use rib cartilage due to its resistance to
infections and reabsorption. He favors allogeneic
rib cartilage because it signi fi cantly shortens the
length of the operation and at the same time mor-
bidity of the donor place is avoided. The survival
of the cartilage as a built-in material is question-
able. Quite often, after a certain period of time,
the implanted parts tend to collapse due to reab-
sorption of the cartilage or to its fi brous degenera-
tion. If the fi brous degeneration was the goal of
placing the crushed cartilage as means of hiding
slight irregularities in the bone area of the nasal
pyramid, it is desirable. In other cases of perform-
ing implantation, it is undesirable. In an experi-
mental study, Kazikdas et al. [ 21 ] compared the
behavior of a cartilage during its implantation
depending on the material it was coated with. In
this study, he coated the cartilage of one group
with oxidized regenerated cellulose, and in the
other group, he used esteri fi ed hyaluronic acid.
He has shown that in case where oxidized regen-
erated cellulose was used, chondrocytes turned
into fi broblasts and the cartilage deteriorated,
whereas in the other group, the cartilage structure
was completely preserved. Garcia-Diaz et al. [ 22 ]
used cortical layer of the tibia in 14 patients as the
autogenic material for fi lling nose dorsum with
satisfactory effect and minimal scar of 1.5 cm in
the place of harvesting the materials. Song et al.
[ 23 ] achieved good results by using commercial
rib cartilage (Tutoplast- processed rib cartilage).
This commercial preparation is used in many
fi elds of medicine where replacement of the carti-
lage tissue is needed.
Conrad presented his retrospective study by
using Gore-Tex [ 24 ] . He states that this material is
extremely convenient for implantation in case of a
revision rhinoplasty. Gore-Tex is expanded poly-
tetra fl uoroethylene, a polymer of carbon fi bers, and
it should represent an inert material for an organ-
ism. When using this material, in minority of cases,
1.95 according to this study, rejection or infection
may appear. They are resolved after the removal of
the implants. In his study, Conrad used implantation
of 1–1 thickness, with the maximum implantation
of 10 mm. Still, Gore-Tex is not an entirely inert
material, and it can lead to a tissue reaction. During
a histological analysis using light microscope as
well as using electronic microscopy, Jang found
numerous changes in 122 patients who had Gore-
Tex implanted for a longer period of time. The
changes occurred in the surrounding tissues as well
as in the implant itself. Proliferation of connective
tissue, numerous calci fi cations, and reactions sur-
rounding the foreign object as well as degeneration
of the tissue holding the implant and the changes in
the structure of Gore-Tex itself were present [ 25 ] .
After shaping the nasal pyramid and cartilagi-
nous skeleton fi xation, the authors place a fi nely
ground deperiostealized cartilage over the bone
part of the nasal pyramid, and if the need arises
the cartilage part as well. Thus, a milder transi-
tion on the osteotomy region is achieved. It is rel-
evant to highlight that when cartilage is without
periosteum and crushed, chondrocytes turn into
fi broblasts, and cartilaginous structures disappear
if the cartilage is used this way (Fig. 25.13 ).
Fig. 25.13 Ground cartilage that helps attain a better
effect
365
25 Rhinoplasty: Open Techniques
At the end of the surgery, soft tissue of the
pyramid is slowly put back down. Incisions are
sown with the thread Prolene 5-0. The nose is
tamponaded and immobilized. Most authors are
of the opinion that nose de-tamponade should be
done only after 48 h. Ours is that tampons should
stay in the nose for 3 or 4 days depending on the
nasal septum pathology. The sutures are removed
on the seventh day postsurgical day, immobiliza-
tion on the tenth day.
References
1. Kljajic V, Savovic S (2011) Rhinoplasty. In: Erian A,
Shiffman MA (eds) Advanced surgical facial rejuve-
nation. Springer, Berlin
2. Ercolani M, Baldaro B, Rossi N, Trombini E, Trombini
G (1999) Short-term outcome of rhinoplasty for medical
or cosmetic indication. J Psychosom Res 47(3):277–281
3. Kljajić V, Novaković B, Savović S, Vlaški Lj,
Erdevički Lj (2010) Modulation of “self-concept” as a
consequence of septorhinoplasty. HealthMED 4(4):
770–774
4. Sood VP, Jain A (2009) Psychological implications in
ENT diseases. Ind J Otolaryngol Head Neck Surg
61:95–98
5. Kljajić V, Savović S, Čanji K (2010) Nasal hump –
fi ve year analysis. Med Pregl 63(3–4):159–162
6. Kljajić V, Čanji K, Savović S (2008) Rhinoplasty –
fi ve years retrospective analysis. Med Pregl 61(Suppl
2):37–40
7. Kljajic V, Erdevicki Lj, Vlaski Lj, Tanackov I, Savovic
S (2011) Respiratory function of the nose after aes-
thetic rhinoseptoplasty. In: 1st congress of CE-ORL-
HNS, Barcelona, 2–6 July 2011. Abstract CD 101
8. Kljajic V (2011) The link of respiratory function and
anthropometric characteristics of nose and the face
before and after rhinoseptoplasty. Ph.D. thesis,
Medical Faculty of Kragijevac, Kragijevac. UDC
616.211–008–089.84:572.087; p 178
9. Roe JO (1887) The deformity termed “pug-nose” and
its correction, by a simple operation. Trans Med Soc
NY: 141–146
10. Weir RF (1892) On restoring sunken noses without
scarring the face. NY Med J 56:449–454
11. Cottle MH, Loring RM, Fischer GC, Gayman IE (1958)
The maxilla-premaxilla approach to extensive nasal
septum surgery. Arch Otolaryngol 68(3):301–313
12. Padovan I (1984) Vanjski pristup u rinoplastici
(Dekortikacija). In: Otorinolaringologija 2, Kirurgija
nosa, paranazalnih šupljina i lica. Školska klnjiga
Zagreb. pp 153–167
13. Bafaqeeh SA, Al-Qattan MM (1998) Open rhino-
plasty: columellar scar analysis in an Arabian popula-
tion. Plast Reconstr Surg 102(4):1226–1228
14. Karaaltin MV, Orhan KS, Demirel T (2009) Fascia
lata graft for nasal dorsal contouring in rhinoplasty. J
Plast Reconstr Aesthet Surg 62(10):1255–1260
15. Jang YJ, Song HM, Yoon YJ, Sykes JM (2009)
Combined use of crushed cartilage and processed fas-
cia lata for dorsal augmentation in rhinoplasty for
Asians. Laryngoscope 119(6):1088–1092
16. Boccieri A, Marano A (2007) The conchal cartilage
graft in nasal reconstruction. J Plast Reconstr Aesthet
Surg 60(2):188–194
17. Karen M, Chang E, Keen MS (2000) Auricular com-
posite grafting to repair nasal vestibular stenosis.
Otolaryngol Head Neck Surg 122(4):529–532
18. Acarturk S, Arslan E, Demirkan F, Unal S (2006) An
algorithm for deciding alternative grafting materials
used in secondary rhinoplasty. J Plast Reconstr
Aesthet Surg 59(4):417–418
19. Huizing EH, de Groot JAM (2003). In: Huizing B, de
Groot J (eds), Functional reconstructive nasal surgery.
Thieme, Stuttgart
20. Tosun Z, Karabekmez FE, Keskin M, Duymaz A,
Savaci N (2008) Allogenous cartilage graft versus
autogenous cartilage graft in augmentation rhino-
plasty: a decade clinical experience. Aesthtic Plast
Surg 32(2):252–260
21. Kazikdas KC, Ergur B, Tugyan K, Guneli E, Kaya D,
Sahan M (2007) Viability of crushed and diced carti-
lage grafts wrapped in oxidized regenerated cellulose
and esteri fi ed hyaluronic acid: an experimental study.
Laryngoscope 117(10):1728–1734
22. Garcia-Diez E, Guisantes E, Fontdevila J, Raigosa M,
Serra-Renom JM (2009) Cortical tibial bone graft for
nasal augmentation: donor site short scar. J Plast
Reconstr Aesthet Surg 62(6):747–754
23. Song HM, Lee BJ, Jang YJ (2008) Processed costal
cartilage homograft in rhinoplasty. Arch Otolaryngol
Head Neck Surg 134(5):485–489
24. Conrad K, Torgeson CS, Gillamn G (2008)
Applications of Gore-Tex implants in rhinoplasty
reexamined after 17 years. Arch Facial Plast Surg
10(4):224–231
25. Jang TY, Choi YJ, Jung HJ, Park HJ, Lim SC (2009)
Histologic study of Gore–Tex removed after rhino-
plasty. Laryngoscope 119(4):620–627
367
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_26, © Springer-Verlag Berlin Heidelberg 2013
26
26.1
Introduction
The nasal valves, both external and internal,
can potentially contribute to the sensation of
obstructed nasal air fl ow. Many etiologies and
nearly as many treatments have been described;
however, the optimal treatment of nasal valve
pathology is still under debate. One such tech-
nique is the intranasal Z-plasty (INZP). First
described by Dutton et al [ 13 ] . for nasal valve
collapse, the INZP offers a minimally invasive
approach to nasal valve collapse with similar suc-
cess to that of more aggressive open techniques.
In this chapter, the anatomy of the nasal valve,
the etiology of collapse, and INZP technique and
results will be described.
26.2
Relevant Anatomy
Mink [ 1 ] fi rst described the nasal valve in 1903 as
a “slit-like opening” within the nasal vestibule
that was further described in 1971 by Hinderer
[ 2 ] to be the angle between the caudal end of the
upper lateral cartilage (ULC) and the nasal sep-
tum. Since this time the nasal valve has come to
be de fi ned posteriorly by the inferior turbinate,
superiorly by the ULC, laterally by the nasal alar
and bony pyriform aperture, inferiorly by the
nasal fl oor, and medially by the cartilaginous sep-
tum. The nasal valve region is further divided
into an external and internal nasal valve. The
external nasal valve is bounded laterally by the
nasal ala and medially by the septum and colu-
mella and lies caudal to the internal nasal valve.
Patency of the external nasal valve hinges on the
support of the lateral border area provided by the
ligamentous attachment of the lateral crus to the
bony maxilla and the competence of the nasalis
and dilator naris muscles. The external nasal
valve typically becomes clinically important sec-
ondary to lateral cartilage weakening and postrhi-
noplasty alar rim pinching.
The internal nasal valve is bordered laterally
and superiorly by the caudal aspect of the upper
lateral cartilage, medially by the septum, and
inferiorly by the pyriform aperture and nostril
fl oor. It is located 2 cm within the nasal cavity
and encompasses a surface area of approximately
20–40 mm 2 on each side. The angle of the valve
is typically 10–15° as measured by the caudal
re fl ection of the upper lateral cartilage and the
The Intranasal Z-Plasty for Nasal
Valve Collapse
Jay M. Dutton , John S. Schneider ,
and Catherine A. Ray
J. M. Dutton , M.D. ()
Division of Rhinology and Facial Plastics,
Department of Otolaryngology ,
Rush University Medical Center ,
1725 W. Harrison, Suite 340 , Chicago ,
IL 60612 , USA
e-mail: jay_dutton@rush.edu
J. S. Schneider , M.D. • C. A. Ray , M.D.
Chicago , IL , USA
368
J.M. Dutton et al.
superior portion of the septum [ 3 ] . This angle has
been noted to vary among races and is generally
more obtuse in African Americans and Asians
than Caucasians. Recently, variation of the inter-
nal nasal valve angle from person to person has
been classi fi ed according to angle type, including
blunt, sharp, or occupied by the septal body, and
according to ULC caudal border status, including
convex, concave, or twisted. This description is
important in that the shape of the valve can con-
tribute to cross-sectional area and turbulence and
can be as important as the actual angle.
26.3
Physiology
The internal nasal valve accounts for 50% of
resistance from the external nasal valve to the
alveoli [ 4 ] , making it the single greatest site of
resistance in the airway. Importance of the cali-
ber of the internal nasal valve is made evident
by knowledge of Poiseuille’s law, which states
that fl ow is proportional to the radius of an
opening to the fourth power (resistance = [veloc-
ity × length]/radius [ 5 ] ). Thus, even minor
changes in nasal valve cross-sectional area will
have drastic effects. It is also important to note
at the level of the internal nasal valve air fl ow
becomes laminar and therefore disruption of
this region generates turbulence, further exacer-
bating dysfunction [ 6 ] .
An important concept when discussing nasal
valve collapse is the function of the internal nasal
valve as a starling resistor. A starling resistor is
de fi ned as a potentially collapsible tube within a
chamber. In the case of the nasal valve, the
fl exibility of its de fi ning structures allows it to
limit fl ow by collapsing when air fl ow is acceler-
ated, with partial collapse of the upper lateral car-
tilages occurring at a fl ow rate of approximately
30 L/min [ 3 ] . Furthermore, the Bernoulli principle
dictates that fl ow speed and pressure are inversely
proportional; therefore, as air fl ows through the
nasal valve, pressure decreases. Pathologic inter-
nal nasal valves may lose structural competence
and succumb prematurely with subsequent col-
lapse and nasal obstruction at lower fl ow rates [ 5 ] .
Negative pressure increases air fl ow resistance
during inhalation and pulls the incompetent nasal
wall toward the septum. Therefore, narrowing of
the nasal valve increases propensity for collapse
[ 7 ] . It has been noted that this mechanism of col-
lapse may serve as protection of the upper respira-
tory system from unheated or unhumidi fi ed air.
Narrowing and collapse can thus be initiated or
exacerbated via mucosal trauma secondary to sep-
toplasty or septorhinoplasty and most notably
endonasal approaches [ 8 ] .
Nasal valve dysfunction can be further subdi-
vided into static and dynamic processes. Static
dysfunction is de fi ned by a perpetual obstruction
of the nasal valve secondary to structural abnor-
malities. The etiologies can include wide colu-
mella, high septal deviation, narrow nasal valve
angle, stenosis, hypertrophied inferior turbinates,
caudal septal deviation, or severely ptotic nasal
tip. Dynamic dysfunction, however, is determined
by the competence of the nasal sidewall at vary-
ing transmural pressures. Components of the
nasal sidewall include muscle, cartilage, and
fi brofatty tissue, and disruption of any of these
structures can lead to varying degrees of nasal
collapse. Separation of the ULC from the septum
during endonasal septoplasty and septorhino-
plasty may also disrupt middle nasal vault sup-
port with inward collapse of the ULCs. Cephalic
trim of the lateral crura and resection of the scroll
between the ULC and LLC can promote weak-
ness and therefore increase risk of collapse.
Disruption of these supporting structures can also
occur during resection of skin neoplasms in the
lateral alar region if the proper measures are not
taken to ensure or restore support.
26.4
Patient Selection
The Z-plasty has been well described in both the
otolaryngology and plastic surgery literature for
scar revision. This technique, fi rst described in
1837, lengthens, breaks up and reorients scar
lines. The procedure transfers lateral skin excess
transversely to lengthen the area along the line of
a tight scar, with the resulting increase in length
369
26 The Intranasal Z-Plasty for Nasal Valve Collapse
relieving contracture. Moreover, the inherent
shape of the z breaks up the lines and further
assists in relief of the contracture
Originally, the INZP was used in limited cases of
cleft nasal deformity and nasal vestibular stenosis
[ 9, 10 ] . However, the expanded use of INZP
includes many potential candidates with varying
types of nasal valve dysfunction. First, however,
the structural abnormalities of the nasal septum
and inferior turbinates must be addressed. A typi-
cal candidate for INZP is a patient who has
already undergone surgical repair of nasal septal
deviations and turbinate hypertrophy, or has had
primary rhinoplasty in some form, but has persis-
tent symptoms of nasal valve obstruction. Of note
it is postulated that the procedure essentially wid-
ens the valve angle and creates a subtle tip rota-
tion, both of which are known to improve nasal
air fl ow, particularly in the geriatric patient.
Evaluation of the patient should include docu-
mentation of the following:
“Cottle maneuver” to document that there is a
•
potential nasal valve obstruction – pulling the
cheek laterally to open nasal valve to demon-
strate improvement in patient’s subjective
nasal obstruction.
Alternatively, a modi fi cation of the Cottle
•
maneuver is performed whereby the lateral
nasal wall may be gently displaced laterally
with a cerumen curette to assess the patient’s
subjective air fl ow.
Anterior rhinoscopy to document anatomic
•
relationships of the upper and lower cartilages
to the nasal septum.
Nasal endoscopy to demonstrate the absence
•
of other pathologies of nasal obstruction such
as polyps or tumors.
Photography to document the appearance of
•
the nose and lateral wall preoperatively.
The ideal candidates for INZP are patients who
present with narrow internal nasal valve angles.
The etiologies may include natural anatomy, prior
surgery, or aging. INZP can sometimes be used
for external valve collapse, but only mild cases.
Those patients usually need open procedures to
address support issues secondary to lateral carti-
lage weakness.
26.5
Procedure
The Z-platsy has long been utilized in facial
plastic surgery. This technique, fi rst described
by Horner [ 11 ] in 1837, transfers lateral skin
excess transversely to lengthen the area along
the line of a tight scar, with the resulting increase
in length relieving contracture13 . In many ways,
the scroll region can be conceptualized as a scar
contracture traversing the nasal valve region in
patients with nasal valve obstruction. The scroll
buckles into the nasal cavity to create obstruc-
tion at the point of maximum obstruction in the
upper respiratory tree, much as a contracture
would in nasal stenosis. While the Z-plasty has
been well described for true stenosis within the
nasal valve [ 12 ] as well as repair of the cleft lip
nasal deformity [ 10 ] , it has not been well
described for narrowing and collapse of the
internal valve angle
The exact con fi guration of the Z-plasty can
vary, such that the greater degree of angulation
can increase the length of a scar line. A 30 degree
angle of the fl aps will affect a 25% increase in the
length of the scar, a 45 degree angle will affect a
50% increase in their length, and a 60 degree
angle will affect a 75% increase in the length. In
the nasal valve region this is a 3-dimensional Z so
the changes are less predictable, but in general
wider angles will affect a greater change in the
valve area and a greater degree of rotation of the
nostril, but similarly may be more dif fi cult to
close because of higher tensions.
The procedure is performed with either intra-
venous sedation or general anesthesia, although
select patients can tolerate an awake procedure
with local anesthesia. Local anesthesia is obtained
by injecting lidocaine, 1%, with 1:100,000 epi-
nephrine into the nasal valve region and anterior
nasal cavity on both sides. The nasal cavity and
face are then prepared with iodine solution, and
sterile drapes are applied to the fi eld. An intercar-
tilaginous incision is then performed, with the
incision made in the scroll region (ridge formed
by the caudal border of the upper lateral cartilage
overlapped by the lateral crus of the lower lateral
cartilage) (Fig. 26.1 ). The Z-plasty incisions are
370
J.M. Dutton et al.
then completed, and the soft tissue is elevated
such that the anterior fl aps are medially based
and the posterior fl aps are laterally based
(Fig 26.1 ). The caudal border of the upper lateral
cartilage is then identi fi ed and removed to make
room to mobilize the Z-plasty fl aps (Fig. 26.1 ).
Removal of cartilage here may seem counterin-
tuitive, but is entirely necessary to free enough
room to mobilize the fl aps. The fl aps are then
interdigitated and sutured into position with 4-0
chromic sutures (Fig. 26.1 ).
The apex of the anterior fl ap is technically
dif fi cult to suture into the posterior fl ap donor
site. This is usually addressed by passing a 6-0
nylon suture through the apex of the fl ap and then
passing it through the fi nal destination (posterior
fl ap donor site) and then externally, where it is
passed through an external bolster composed of a
a
b
c
d
Fig. 26.1 Intranasal Z-plasty procedure. ( b ) The incisions
are created such that the central incision is an intercarti-
laginous incision, and the side incisions are oriented such
that the anterior fl ap will be medially based and the poste-
rior fl ap will be laterally based. ( b ) The triangular fl aps A
and B are then elevated. Note the underlying caudal bor-
der of the upper lateral cartilage. ( c ) The caudal border of
the upper lateral cartilage ( shaded area ) is then removed
to make room for mobilization of fl aps A and B. ( d ) The
fl aps are then interdigitated and sutured into position
371
26 The Intranasal Z-Plasty for Nasal Valve Collapse
silastic disk or dental roll. The suture is then
passed back internally through the posterior fl ap
donor site and then around a second dental roll
bolster or a concave silastic tube. The internal
bolster is then packed snugly into the internal
valve region, and the suture is tightened. If a con-
tralateral procedure is indicated, the second side
is addressed in an identical fashion. Antibiotic
ointment is then applied to the bolsters and all
suture lines, and the bolsters are left in place for
7–10 days. The patient is administered oral anti-
staphylococcal antibiotics (to prevent wound
infections and toxic shock syndrome) and oral
pain medications.
26.6
Results
In our original study, 12 patients were identi fi ed
over a 2-year period with nasal valve obstruction
without stenosis. Ten patients had undergone
prior surgical attempts to address nasal and sinus
problems but had persistent subjective nasal
obstruction believed to be secondary to internal
nasal valve collapse [ 10 ] . Two of these were
believed to be iatrogenic. One patient had under-
gone a rhinoplasty 12 years before the Z-plasty
and two separate revision rhinoplasties that were
unable to relieve his subjective obstructive com-
plaints. Another patient had undergone removal
of basal cell carcinoma from the alar skin, and his
postoperative obstruction was not improved with
subsequent alar batten grafts. The remaining ten
cases were secondary to the patients’ inherent
nasal anatomy. Of these, eight patients had under-
gone prior septoplasty and turbinoplasty, and fi ve
patients had undergone prior endoscopic sinus
surgery, although none of these procedures
improved their complaint of nasal obstruction.
The mean (range) age of patients undergoing
this procedure was 49.58 years (26–71 years).
This population included eight men and four
women. The mean (range) follow-up was
16.75 months (5–32 months). Ten patients under-
went bilateral surgery, with two patients undergo-
ing unilateral surgery. No perioperative or
postoperative complications were identi fi ed. No
patients complained of abnormal postoperative
aesthetics.
On a scale of 0–10, with ten being total nasal
obstruction and zero being no nasal obstruction,
the mean preoperative score was 7.17, and the
mean postoperative score was 3.2. This statistic
was further analyzed with a paired t test, and
the results showed that there was a mean
improvement from preoperative score to post-
operative score of 3.92. This score was statisti-
cally signi fi cant ( P <.001). The patients
appeared to bene fi t signi fi cantly from the pro-
cedure (Fig. 26.2 ).
a
b
Fig. 26.2 ( a ) Right nasal valve before Z-plasty. ( b ) Right nasal valve after Z-plasty
372
J.M. Dutton et al.
Conclusions
INZP is an important tool in any rhinoplasty
surgeon’s armamentarium to address nasal
valve obstruction or stenosis. The procedure is
minimally invasive and can be performed in
the of fi ce setting. Further studies are needed
to compare this technique to other nasal valve
techniques, although preliminary experience
with
this
procedure
has
been
very
encouraging.
References
1. Mink PJ (1903) Lez comme voie respiratoire. Presse
Otolaryngol (Beige) 21:481–496
2. Hinderer KH (1971) Surgical anatomy. In: Hinderer
KH (ed) Fundamentals of anatomy and surgery of the
nose. Aesculapius Publishing Co., Birmingham
3. Adamson JE (1987) Constriction of the internal nasal
valve in rhinoplasty: treatment and prevention. Ann
Plast Surg 18(2):114–121
4. Cole P, Haight JS, Love L, Oprysk D (1985) Dynamic
components of nasal resistance. Am Rev Respir Dis
132(6):1229–1232
5. Park S (1999) Treatment of the internal nasal valve.
Facial Plast Surg Clin North Am 7(3):333–345
6. Lane AP (2004) Nasal anatomy and physiology.
Facial Plast Surg Clin North Am 12(4):387–395
7. Mendelson MS, Golchin K (2006) Alar expansion
and reinforcement, a new technique, to manage nasal
valve collapse. Arch Facial Plast Surg 8(5):
293–299
8. Beekhuis GJ (1976) Nasal obstruction after rhino-
plasty: etiology, and techniques for correction.
Laryngoscope 86(4):540–548
9. Donald PJ (1995) Minor intranasal procedures. In:
Donald PJ, Gluckman JL, Rice DH (eds) The sinuses.
Raven, New York, pp 641–655
10. Dutton JM, Bumsted RM (2001) Management of the
cleft lip nasal deformity. Facial Plast Surg Clin North
Am 9(1):51–58
11. Horner W (1837) Clinical report on the surgical
department of the Philadelphia Hospital, Blockley for
the months of May, June, July 1837. Am J Med Sci
21:105
12. Murakami CS, Nishioka GJ (1996) Essential
Concepts in the Design of Local Skin Flaps. Facial
Plastic Surgery Clinics of North America. 1996(4)
455–464
13. Dutton JM, Neidich MJ (2008) Intranasal z-plasty for
nasal valve collapse. Arch Facial Plast Surg. 2008;10(3):
164–168
373
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_27, © Springer-Verlag Berlin Heidelberg 2013
27
27.1
Introduction
Nasal rim and nasal valve deformities may result
in nasal obstruction and/or nasal aesthetic
de fi ciencies. Surgical reconstruction of this criti-
cal area of the nose may be performed by multi-
ple different approaches and techniques.
The method presented in this chapter was
introduced in 2000, comparing the newly devel-
oped nasal alar rim reconstructive procedure to
the traditional nasal valve cartilage graft tech-
nique [ 1, 2 ] . Numerous techniques have been
devised to treat collapse of the anterior external
nose. The goal of this reconstruction is a reliable,
structurally sound, functional support, while not
adversely altering facial aesthetics. The most
effective methods have used cartilage or compos-
ite grafts to function as structural grafts or as
spreader grafts. These grafts either enlarge the
diameter of the internal nasal valve, strengthen
the lateral crura of the lower lateral cartilage pre-
venting collapse, or support connections of the
lower lateral cartilage to the pyriform aperture.
27.2
De fi ning the Internal
and External Nasal Valve
The external nasal valve is de fi ned as the external
opening of the nostril. The external nasal valve
includes the length of the nasal rim from the nasal
tip to the pyriform aperture. Collapse of the exter-
nal nasal valve and nasal rim is synonymous. The
internal nasal valve is the area of the junction of
the caudal edge of the upper lateral cartilage with
the nasal septum. When the lateral crura of the
lower lateral cartilage is weak, the anterior and
midportions of the length of the nasal rim, which
are directly supported by the underlying carti-
lage, may collapse. The posterior aspect of the
alar rim has no cartilage support; however, it is
held in place by the thick alar skin and rarely col-
lapses. The physiology of the nose reveals the
internal nasal valve as the narrowest site of the
nasal airway and accounts for more than 50% of
the total airway resistance [ 3– 5 ] .
27.3
Alternative Internal
and External Valve
Reconstructive Options
Presently, there are a variety of alternative thera-
peutic cartilage reconstruction grafts of the nasal
tip including lateral crural strut grafts, alar
spreader grafts, and alar contour grafts [ 2, 6– 10 ] .
The endonasal nasal rim and valve reconstructive
method (NARR) answers the de fi ciencies of pre-
vious methods and offers a reliable, technically
Nasal Alar Rim Reconstruction
for Nasal Rim and Valve Collapse
Robert J. Troell
R. J. Troell , M.D.
7975 W. Sahara Avenue, Suite 104 , Las Vegas ,
NV 89117 , USA
e-mail: rjtroell@gmail.com
374
R.J. Troell
simple, structurally sound and cosmetically pleas-
ing procedure to strengthen the nasal valve and
rim area [ 1 ] .
27.4
Surgical Approaches
The surgical approaches can use either the endo-
nasal, commonly referred to as the closed approach,
or the transcolumella, or external method, com-
monly referred to as the open approach. The deci-
sion to choose one approach over the other is
mainly due to the surgeon’s preference and experi-
ence. The other determinants for choosing the
speci fi c approach is the complexity of the patient’s
deformity, amount of skin and/or scarring of the
soft tissue envelope, reconstruction options, and
the patients input. The open method allows an
unabated and undistorted anatomical exposure of
the entire nasal framework. This exposure allows
both an accurate assessment of the nasal deformity
as well as superior exposure to facilitate correction
of deformities using cartilage graft reconstruction.
Some believe that dif fi cult cases should be
addressed through the endonasal approach,
because intraoperative judgments on reconstruc-
tion are best from a skin surface that is undisturbed
and maximally vascularized [ 11 ] .
27.5
Indications for Nasal Rim
and Valve Reconstruction
The indications for nasal rim and valve recon-
struction include nasal obstruction, refractory to
medical treatment with oral antihistamines and
nasal steroid sprays for at least 1 month duration.
De fi ciencies of support of the anterior nose may
result from congenital abnormalities or acquired
through one of the following: the aging process,
blunt and penetrating trauma, a signi fi cant infec-
tion and iatrogenically from rhinoplasty proce-
dures. Many patients presenting with recalcitrant
nasal obstruction who have underwent previous
nasal septoplasty and bilateral partial inferior tur-
binate reduction surgery usually require address-
ing the nasal rim and/or nasal valve. However,
the optimal treatment strategy is to perform all
nasal procedures that are required to resolve the
problem at one surgical session. In this scenario,
the quadrangular cartilage addressed during the
septoplasty can be maximized in size and used as
the preferred autologous cartilage nasal strut.
The other indication for nasal rim and/or valve
reconstruction is to repair an aesthetic deformity
as in a primary or, more commonly, in a second-
ary rhinoplasty. Often in secondary rhinoplasty,
there is alteration in structure and function result-
ing in either a cosmetic deformity, nasal obstruc-
tion, or both [ 11, 12 ] .
27.6
Cartilage Harvesting
and Grafting Sources
The options for cartilage struts include septal,
auricular, autologous costal, and irradiated allograft
costal cartilage. The reason septal cartilage is the
preferred choice for structural reconstruction is
that it is readily available in the surgical fi eld, usu-
ally with suf fi cient quantity, the shape is fairly
straight, and the strength is stronger than auricular
conchal cartilage. The advantage of auricular car-
tilage is the ease of harvesting, the potential large
quantity from using either one or both ears, and
straight as well as curved shapes. However, the
disadvantages are a more fl accid strength than sep-
tal or costal cartilage, occasionally requiring two
pieces of conchal cartilage sutured together due to
size or strength issues and the harvested auricular
cartilage shape may not be optimal for the purpose
of the cartilage graft [ 7 ] .
Harvesting costal cartilage is another alterna-
tive option when the quantity of available septal
cartilage and auricular cartilage is insuf fi cient.
The advantages are the amount of structural sup-
port this cartilage provides, the vast quantity that
is available, versatility in size and shape of grafts.
The disadvantages include the need of a separate
operative site and incision, chest scar presence,
increased postoperative discomfort, the need for
general anesthesia, the risk of pneumothorax,
presence of rib ossi fi cation making handling
more dif fi cult and the potential for the cartilage
to warp. Use of the fi fth, sixth, and seventh ribs
are most often chosen for harvesting [ 9 ] .
375
27 Nasal Alar Rim Reconstruction for Nasal Rim and Valve Collapse
The advantage of irradiated rib cartilage is
the lack of a donor site. Disadvantages include
the dif fi culty in locating available donated carti-
lage from tissue banks, the risk of errors in tissue
processing causing bacterial or viral infections,
the weakened cartilage as a result of irradiation
and nonviable cellular tissue, and the increased
risk of cartilage warping noted in costal cartilage
[ 13– 15 ] .
The author prefers using septal cartilage as the
nasal rim and nasal valve reconstruction graft. If
insuf fi cient quantities exist, auricular cartilage is
used as a single or double thickness graft. In con-
trast to the initial manuscript, these two alterna-
tives can be used in nearly all clinical situations,
making the need for irradiated costal or autolo-
gous costal cartilage unnecessary.
27.7
Diagnosis of Nasal Rim and/or
Nasal Valve Collapse
The fi rst step in nasal rim and/or nasal valve recon-
struction is the proper diagnosis of a deformity.
An anterior internal nasal examination or rhinos-
copy with a nasal speculum is undertaken. One
notes the position of the nasal septum, enlarge-
ment of the inferior and middle turbinates, and
existence of nasal pathology to include: polyps,
tumors, septal perforation, crusting, in fl ammatory
conditions or synechiae. However, it is important
to be vigilant, because the nasal speculum itself
can hide the diagnosis of a weakened alar rim or
collapse of the internal or external nasal valve.
Visualization of the external appearance of the
anterior nose from the anterior, base and lateral
views as well as palpation of the nasal tip and
nostrils can determine a weakness of the struc-
tural support of the anterior nose. Use of the
Cottle maneuver or cotton-tipped applicators to
open the internal and external valve may con fi rm
the diagnosis. A trial of Nasovent springs or nasal
valve adhesive strips (Nasal Breathrite Stips ® )
can also assist in the diagnosis. These devices
may produce symptomatic improvement in
breathing from either isolated enlargement of the
nasal valve area or prevention of collapse of this
area. Additional testing may be considered to
rule out other causes or sites of obstruction, such
as fi beroptic nasopharyngoscopy, rigid nasal
endoscopy, acoustic rhinoscopy, or the topical
decongestant test using either 0.05% oxymetazo-
line (Afrin ® test) or 0.25% phenylephrine hydro-
chloride. Acoustic rhinometry cannot diagnose
reduced nasal air fl ow at the nasal rim area,
because the nosepiece of the measuring device
itself stents the area of concern open [ 1 ] .
The nasal alar rim reconstructive procedure
(NARR), through the endonasal approach, has
the advantage in secondary rhinoplasty of ease of
technique, limited dissection, avoidance of the
often scarred domal area, and optimized skin and
soft tissue vascularization [ 1, 11 ] .
27.8
The Surgical Technique Steps
27.8.1 Anesthesia
The type of anesthesia is determined by several
factors, including the source of the harvested car-
tilage; associated surgical procedures being per-
formed, such as a septoplasty, rhinoplasty, or
other cosmetic or reconstructive procedures; and
patient, anesthesiologist, and surgeon prefer-
ences. All patients undergo injection of the nasal
envelope using lidocaine with epinephrine for
both anesthesia and hemostasis.
27.8.2 Surgical Preparation
Preoperative examination determines the exact
size and location for placement of a structural
cartilage graft to optimally treat the anterior nasal
collapse (Fig. 27.1 ). The graft placement may
vary from the rim itself or throughout the entire
surface area of the lower lateral (alar) cartilage
up to the caudal edge of the upper lateral carti-
lage. This location is drawn on the skin with a
marking pen.
Preoperative antiseptic treatment can begin
2 weeks prior to surgery in patients with known
colonization of methicillin-resistant staphylococ-
cus aureus (MRSA) with Mupirocin (Bactroban ® ).
Antibiotic therapy is administered within 1 h
376
R.J. Troell
prior to commencement of surgery. The antibi-
otic chosen is either cephalexin or clindamycin,
if penicillin/cephalosporin allergy, and is pre-
scribed for a 7 day duration. Betadine preparation
solution disinfects the skin, including the vesti-
bule skin. Betadine is used on the face, in contrast
to chlorhexidene, to avoid the risk of in fl ammatory
conjunctivitis. Sterile towels and drapes are
placed. Even though septal (quadrangular) carti-
lage is the preferred donor site, one or both ears
are prepared in the surgical fi eld, in case a con-
chal auricular cartilage is needed.
27.8.3 Cartilage Harvesting
A septoplasty is performed to straighten the quad-
rangular cartilage or bony septum and/or to acquire
cartilage for the nasal valve structural grafts. If
insuf fi cient cartilage is present, an auricular carti-
lage graft is acquired. Care is taken to ensure that
the perichondrium remains intact on one side of
the harvested cartilage to improve its viability and
decrease absorption. The author prefers a poste-
rior conchal incision to hide the incision.
If the length and width of a single piece of car-
tilage is not suf fi cient, cartilage remnants can be
directly sutured together or sutured to a polydiox-
anone (PDS) absorbable plate (Ethicon/Mentor,
Irving, TX). Horizontal mattress sutures are
placed at each end of the graft to immobilize the
cartilage pieces. The author prefers to use 5-0
PDS suture.
The ends of the grafts are beveled to allow
easier insertion into the created pockets below
the vestibule skin and under the lower lateral
cartilage.
27.8.4 Cartilage Graft Fabrication
Once the cartilage for grafting is acquired, the
size and strength are evaluated. If the strength is
suf fi cient given the thickness of the skin of the
nasal ala, presence of nasal vestibule skin scar-
ring and the status of the endogenous lower lat-
eral cartilage, the structural graft is constructed.
The graft size is measured with a caliper or ruler
for symmetry (Fig. 27.2 ), and the cartilage is cut
with a 15 blade to this measured size (Fig. 27.2 ).
The ends are beveled to allow ease of placement.
27.8.5 Incisions
There are two locations that can be used for the
NARR procedure: perpendicular to the rim or
parallel to the nasal rim. In most instances, a
a
b
Fig. 27.1 Measuring is essential. ( a ) Length on the external nose from the paradomal area to the lateral extent of lower
lateral cartilage. ( b ) Proposed structural cartilage graft length
377
27 Nasal Alar Rim Reconstruction for Nasal Rim and Valve Collapse
4–5 mm in length incision, perpendicular to the
rim in the vestibular skin, about one-third the dis-
tance from the nasal tip to the piriform aperture is
marked with a marking pen (Fig. 27.3 ). The inci-
sion is performed with a 15 blade in one of these
two alignments. The incision depth ensures that
the vestibule skin is cut, while not extending the
incision deeper into the lower lateral cartilage
itself (Fig. 27.4 ).
27.8.6 Dissection
With the perpendicular incision, a Joseph scissor
undermines the vestibule skin toward the nasal tip
as well as toward the piriform aperture. The
length of the pocket needs to be longer toward
the pyriform aperture (Fig. 27.5 ). This will allow
the graft to be pushed laterally prior to being
pulled back toward the nasal tip in the smaller
a
b
c
Fig. 27.2 ( a – c ) Cutting to the
measured cartilage to the
measured size and shape
optimizing support without
placing too large a graft that
may affect aesthetic
appearanc e
378
R.J. Troell
medial pocket. Care is taken not to perforate the
skin, which may expose the cartilage graft.
Dissection along the incision parallel to the rim,
known as a rim incision, is performed carefully to
ensure leaving closed pockets toward the nasal tip
and also toward the pyriform aperture (Fig. 27.5 ).
These subcutaneous closed pockets will protect
the cartilage from movement or extrusion. The
location of the created pockets is determined by
the preoperative assessment at the maximum area
of collapse. The size of the pocket is about 2 mm’s
greater than the width of the cartilage.
27.8.7 Graft Placement
The proper location and size of the structural car-
tilage grafts are con fi rmed (Fig. 27.6 ). Prior to
a
b
Fig. 27.3 Vestibule incision location. Demarcated with surgical marking pen either: ( a ) Perpendicular to the nasal rim.
( b ) Parallel to the rim as a rim incision
a
b
Fig. 27.4 Vestibule incision with a 15 blade. ( a ) Perpendicular to the nasal rim. ( b ) Parallel to the rim as a rim incision,
however, does not extend the entire length to allow a medial and lateral pocket to be developed
379
27 Nasal Alar Rim Reconstruction for Nasal Rim and Valve Collapse
graft placement, the nasal vestibule is again steril-
ized with betadine using a cotton tip applicator (Q
tip). The graft immediately prior to placement is
soaked in betadine solution (Fig. 27.7 ). With the
perpendicular incision method, the placement
into the lateral dissected pocket is performed fi rst.
The graft needs to be pushed deeper into this lat-
eral pocket than the fi nal position to allow transfer
into the medial pocket (Fig. 27.8 ). This is the most
dif fi cult step, which can be aided by using single
or small double skin hooks to open the medial
pocket. Additionally, a Freer or Cottle elevator
may aid in pushing the graft initially into the
medial pocket. A brown Addison forceps can then
pull the graft from lateral to medial, fi ne-tuning
the fi nal position to optimize both strength and
cosmetic appearance (Fig. 27.8 ). With the rim
incision, the placement is simpler, since there is
more visualization of the surgical fi eld. However,
the lateral pocket still must be dissected suf fi ciently
to allow medial graft placement adjacent to the
most medial aspect of the lower lateral cartilage.
a
c
b
Fig. 27.5 Pocket dissection with Joseph scissors. The
perpendicular incision requires: ( a ) A longer lateral
pocket. ( b ) Shorter medial pocket. ( c ) The rim incision
dissection is performed below the lower lateral cartilage,
creating a medial and lateral pocket
380
R.J. Troell
27.8.8 Auricular Cartilage Graft
Acquisition
The postauricular incision hides the incision
from the anterior view of the face (Fig. 27.9a ).
The auricular cartilage is harvested to a size pre-
determined to be suf fi cient to repair the amount
of collapse. The septal or quadrangular cartilage
is acquired fi rst, and if there is inadequate quan-
tity, then attention is turned to the pinna. The
auricular graft should contain the perichondrium
on at least one side, to decrease the risk of absorp-
tion (Fig. 27.9 ).
After the graft is acquired, it needs to be cut to
the proper size (Fig. 27.10 ). As with septal carti-
lage harvesting, if the length and width of a single
piece of conchal cartilage are insuf fi cient, carti-
lage remnants can be directly sutured together
(Fig. 27.11 ) or sutured to a polydioxanone (PDS)
absorbable plate (Ethicon/Mentor, Irving, TX).
The position is noted on the external skin, and an
evaluation of suf fi cient graft size and proper posi-
tion is con fi rmed (Fig. 27.12 ). Since the auricular
cartilage tends to be structural weaker than the
septal cartilage, a rim incision for placement
decreases the risk of graft fracture (Fig. 27.13 ).
27.8.9 Closure and Dressing
Placement
After the grafts are placed, the nose is examined
for structural support and aesthetic appearance.
Once support and symmetry are con fi rmed, the
incision is closed with simple, interrupted,
Fig. 27.7 Antibiotic solution preparation. Cartilage
grafts are soaked in Betadine solution immediately prior
to placement
a
b
Fig. 27.6 ( a , b ) Con fi rmation of nasal rim and valve reconstruction septal cartilage graft size and position for placem ent
381
27 Nasal Alar Rim Reconstruction for Nasal Rim and Valve Collapse
a
c
e
d
b
Fig. 27.8 Cartilage graft placement. ( a , b ) The perpendicu-
lar incision method places the graft initially into the lateral
pocket. ( c , d ) The graft is pushed to the extent of the lateral
pocket in order to pull it into the medial pocket. ( e ) A brown
Addison forceps pulls the graft medially, aided by using
single or small double skin hooks to open the medial pocket
382
R.J. Troell
absorbable sutures, such as 5-0 chromic
(Fig. 27.14 ). Bacitracin ointment is placed.
Occasionally, Steri-Strips aid in stabilizing the
position of the grafts for a duration of 5–7 days.
If the skin envelope of the nose was elevated
above the lower lateral cartilages, an aqua splint
or Denver splint may be used to minimize the risk
of excess blood collection. Rarely, a short telfa
pack is placed in the nasal valve area for 1 or
3 days postoperatively. Auricular grafts require a
standard Mastoid pressure dressing, kept in place
for 2 days postoperatively (Fig. 27.15 ).
The operative time for the endonasal nasal rim
and valve reconstructive method takes about
20–30 min. Most patients can have the procedure
performed with oral sedation and local anesthe-
sia. There is greater than a 95% patient satisfac-
tion rate regard to alleviating recalcitrant nasal
obstruction and/or improving cosmetic appear-
ance (Figs. 27.16 and 27.17 ).
a
b
Fig. 27.9 Auricular cartilage graft acquisition. ( a ) Postauricular incision midway up the concha wall. ( b ) Conchal
cartilage graft after harvesting
Fig. 27.10 Auricular
cartilage graft fabrication.
Cutting to size and shape
383
27 Nasal Alar Rim Reconstruction for Nasal Rim and Valve Collapse
Fig. 27.11 Auricular
cartilage graft fabrication. If
necessary, overlapping
cartilaginous pieces for
increased strength or length
a
c
b
Fig. 27.12 Con fi rmation of nasal rim and valve reconstruction auricular cartilage graft size and position for placement.
( a ) Original conchal graft. ( b ) Fabricated graft. ( c ) Fabricated graft
384
R.J. Troell
a
b
Fig. 27.13 Rim incision, cartilage placement. ( a )
Retraction of skin after dissection under lower lateral car-
tilage with a Joseph scissor. ( b ) Placement of the auricular
cartilage graft centrally, then pushed into the lateral and
ultimately, the medial pockets
a
b
Fig. 27.14 ( a , b ) Incision closure with absorbable
sutures
Fig. 27.15 Mastoid dressing and nasal splint placement
385
27 Nasal Alar Rim Reconstruction for Nasal Rim and Valve Collapse
a
c
b
Fig. 27.16 Surgical results of nasal rim and valve reconstruction procedure. ( a ) Preoperative nasal base. ( b )
Postoperative nasal base. ( c ) Alar collapse
a
b
c
Fig. 27.17 Surgical results of nasal rim and valve reconstruction procedure. ( a ) Preoperative nasal base. ( b )
Postoperative nasal base. ( c ) Structural cartilage placement
Acknowledgement
Tina M. Kameron, B.A., CRTT for
her intra-operative photographic expertise and editing of
the manuscript
References
1. Troell RJ, Powell NB, Riley RW, Li KK (2000)
Evaluation of a new procedure for nasal alar rim and
valve collapse: nasal alar rim reconstruction.
Otolaryngol Head Neck Surg 122(2):204–211
2. Goode RL (1985) Surgery of the incompetent nasal
valve. Laryngoscope 95(5):546–555
3. Van Dishoeck HA (1942) Inspiratoy nasal resistance.
Acta Otolaryngol 30:431–439
4. Cottle MH (1955) The structure and function of the
nasal vestibule. Arch Otolaryngol 62(2):173–181
5. Haight JS, Cole P (1983) The site and function of the
nasal valve. Laryngoscope 93(1):49–55
6. Sheen JH (1984) Spreader graft: a method of recon-
structing the roof or the middle nasal vault following
rhinoplasty. Plast Reconstr Surg 73(2):230–239
7. Stucker FJ, Hoasjoe DK (1994) Nasal reconstruction
with conchal cartilage: correcting valve and lateral
386
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nasal collapse. Arch Otolaryngol Head Neck Surg
120(6):653–658
8. Dingman RO, Grabb WC (1961) Costal cartilage
homografts preserved by irradiation. Plast Reconstr
Surg 28:562–567
9. Chait LA, Fayman MS (1988) Treatment of post-
reconstructive collapsed nasal ala with costal cartilage
graft. Plast Reconstr Surg 82(3):527–530
10. Gunter JP, Friedman RM (1997) Lateral crural strut
graft: technique and clinical applications in rhino-
plasty. Plast Reconstr Surg 99(4):943–952
11. Constantian MB (1994) The incompetent external
nasal valve: pathophysiology and treatment in pri-
mary and secondary rhinoplasty. Plast Reconstr Surg
93(5):919–931
12. Juri J, Juri C, Grilli DA, Zeaiter MC, Vazquez GD
(1988) Correction of the secondary nasal tip and of
alar and/or columellar collapse. Plast Reconstr Surg
82(1):160–165
13. Donald PJ, Col A (1982) Cartilage implantation in
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Otolaryngol Head Neck Surg 90(1):85–89
14. Welling DB, Maves MD, Schuller DE, Bardach J
(1988) Irradiated homologous cartilage grafts: long-
term results. Arch Otolaryngol Head Neck Surg
114(3):291–295
15. Kridel RW, Koonior RJ (1993) Irradiated cartilage
grafts in the nose: a preliminary report. Arch
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387
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_28, © Springer-Verlag Berlin Heidelberg 2013
28
28.1
Introduction and General
Aspects
Rhinoplasty is one of the mostly performed facial
aesthetic procedures. The surgeon, who is deal-
ing with facial aesthetics, tries to achieve an aes-
thetic harmony with the surrounding facial
features and preserve the nasal function and sup-
port. To achieve these results, nasal osteotomy
must be done successfully [ 1 ] . In general nasal
osteotomy is used to reposition and to reshape the
nasal bones. Repositioning of the nasal bones
usually relocates the bones more medially by
moving the base of the nasal bone from its junc-
tion with the frontal process of the maxilla.
Reshaping usually corrects excessive convexity.
Among osteotomy, lateral nasal wall osteotomy
has an important role. Lateral osteotomy in rhi-
noplasty is commonly used to close an open nasal
roof after hump resection, to correct asymmetric
lateral wall, to strengthen the deviated bony
framework, and to narrow the nose [ 2– 4 ] .
Several techniques for producing lateral nasal
osteotomies have been described in the past century,
yet no consensus has been established regarding the
optimal method [ 5 ] . The selection of technique and
instrumentation is often the surgeon’s preference
and experience but must also depend on some fac-
tors like predictable control, precision, reproduc-
ibility, and association with minimal potential for
complications [ 3 ] . To accomplish a successful
osteotomy, the surgeon must be able to mobilize the
bones and to ensure stability after the surgery.
Mobilization can be adequate if the fracture is com-
plete. This can be done either by osteotome or man-
ually. Manual fractures create greenstick fractures,
which are less predictable but tend to be more sta-
ble. In rhinoplasty, the anatomy and the function of
the nose must be studied and understood completely.
So a complete and detailed workout of the nose
anatomy and function is essential in rhinoplasty
operations. To perform a successful osteotomy, the
surgeon should consider the intrinsic anatomy
(thickness, size, and attachments of the nasal pyra-
mid), instrumentation, surgical approach, and the
patients’ expectations. Good preoperative evalua-
tion of these factors will yield a perfect result.
28.2
Anatomy
28.2.1 Bone and Cartilage Framework
The bony framework of the nose is composed of
paired nasal bones that articulate with each other
in the midline and to the frontal bone superiorly.
Lateral Osteotomy in Rhinoplasty
Rauf Tahamiler and Murat Yener
R. Tahamiler , M.D. (*)
Tus Ent Center , Sehit Evliya Sok. Güzel, Apt. No: 22/7 ,
Senesenevler, Suadiye, Istanbul tr-34740 , Turkey
e-mail: tahamiler@gmail.com
M. Yener , M.D.
Beylerbeyi Bayiri Sokak no:3 , Beylerbeyi, Uskudar,
Istanbul 34676 , Turkey
Department of Otolaryngology , Istanbul University
Cerrahpasa School of Medicine ,
Kocamustafapasa, Fatih, Istanbul , Turkey
e-mail: hmuratyener@gmail.com
388
R. Tahamiler and M. Yener
The region where the nasal bones and the frontal
bone articulate is known as the nasion. The lateral
attachment of the nasal bones is the ascending
process of the maxilla. Nasal bones also articulate
with the perpendicular plate of the ethmoid bone
in the posterior midline region. These bones
together form the bony vault of the nose. It is also
important to note that the bones that form the nose
vary in thickness; nasal bones are thick superiorly
and in the midline along the nasal dorsum and thin
laterally, and thickness increases more laterally
over the maxilla. This variability of thickness
affects the success and the location of osteotomy.
Nasal septum supports the nose along its entire
length. Inferiorly nasal bones overlap the cephalic
portions of the upper lateral cartilages to support
the cartilaginous vault of the nose. The paired
upper lateral cartilages are continuous with the
nasal septum medially. The angle between
the upper lateral cartilages and the nasal septum is
the internal nasal valve. The cartilages are fused
with the frontal process of the maxilla by fi brous
tissue. The paired lower lateral cartilages form the
nasal lobule and the nostrils, which are supported
by nasal septum and nasal spine medially and
small accessory cartilages laterally.
28.2.2 External Landmarks
and Soft Tissues
The soft tissues over the bony vault are namely
skin, subcutaneous tissue, super fi cial muscu-
loaponeurotic system, and the periosteum. The
shape of the nose is composed of the bony vault
as well as the soft tissues over the bones. Two
lateral walls, dorsum, and nasofrontal angle
de fi ne the upper third of the nose. Nasofrontal
angle is the deepest and the most inferior portion
of the nasal dorsum, whereas the nasion is the
junction point of nasal bones to the frontal bone.
The radix or root of the nose corresponds to the
junction of the nasal and frontal bones, and this
should be located at the level of the supratarsal
crease. Rhinion is the junction point of the nasal
bones inferiorly to the upper lateral cartilages.
The nasal bones and the cartilages of the nose are
covered by soft tissue and skin that differs in
thickness in different parts of the nose. The skin
and subcutaneous tissue is thicker at nasofrontal
angle, nasion, and supratip region and thinner
over the rhinion, middorsal region, osteocarti-
laginous junction, and upper lateral cartilages
and thins toward the nasal tip [ 6 ] .
The soft tissues over the nasal bone are differ-
ent in thickness, and taking this information into
consideration is important to achieve straight
appearance of the pro fi le; one must leave a small
hump at the junction of osteocartilaginous region
to avoid a small saddlenose deformity after dor-
sal hump reduction. Nasal muscles lie deep to the
nasal skin and subcutaneous tissue. The super fi cial
musculoaponeurotic system (SMAS), which is
composed of collagen fi bers, surrounds these
muscles, and main arteries and nerves of the nose
are deep to SMAS. The dissection during rhino-
plasty must be done deep to SMAS.
The periosteum lies between the bone and the
soft tissue envelope. It may be helpful to raise the
fl ap including the periosteum to achieve better
camou fl age and decrease the risk of postopera-
tive trophic changes. Laterally the periosteum
should be minimally elevated through the maxil-
lary process to stabilize the bony fragments
following lateral osteotomies.
It is important to note that the soft tissue and
bony framework change with age. At a younger
age the osteotomies may result in greenstick frac-
tures, which makes it hard to mobilize the frac-
tured segments. So in young patients, continuous
osteotomies must be done to avoid greenstick
fractures and to accomplish proper mobilization.
28.3
Evaluation
Patients who are candidate to a nasal aesthetic
procedure should be evaluated by complete
medical history fi rst. Prior nasal trauma, nasal
surgery, and nasal breathing problems should be
noted. It is very important to de fi ne the deformi-
ties so that more suitable osteotomies can be
performed. During the evaluation, the surgeon
should visualize and palpate the nasal anatomy
389
28 Lateral Osteotomy in Rhinoplasty
and predict the underlying structures. During
nasal analysis, the nose must be divided into
three parts horizontally. The upper third repre-
sents the bony vault, mid-third represents the
cartilaginous framework, and the lower third
represents the tip region.
On anterior evaluation, the length, width, and
deformities and deviations of the nasal bones
must be noted. The width of the nasal dorsum
should ideally be two-thirds of the width of the
alar base, and the alar base should approximate
the intercanthal distance.
Palpation of the nasal bones and maxilla is
important to de fi ne any irregularity or displace-
ment. The concavity or convexity of the bones
must be noted as convex deformity may require
an intermediate osteotomy. The height of the
nasal bones should also be evaluated.
The nasofrontal angle (between glabella-
nasion line and nasion-tip line) should be 115–
130°. High radix-shallow nasofrontal angle or
low radix-high nasofrontal angle should be man-
aged individually. Intanasally evaluation is also
important to de fi ne septal deformities, valve
obstruction, or turbinate hypertrophy. Function
of the nose must be restored while managing the
aesthetic appearance.
28.4
Instrumentation
There are different types of osteotomes that can be
used in lateral osteotomy. Generally the choice of
the osteotome and the surgical approach depends on
the experience of the surgeon. Narrow, wide, straight,
curved, or guarded osteotomes can be used for this
purpose. The blades may be 3 or 5 mm in width and
the bodies may be straight or curved. Also guarded
or unguarded osteotomes may be used. Unguarded
narrow osteotomes can cause minimal soft tissue or
mucosa injury, but experienced surgeons can use
these instruments reliably. To accomplish percutane-
ous lateral osteotomy, 2-mm straight osteotome can
be selected. In their study, Erişir et al. [ 7 ] described a
novel osteotome with minimal postoperative hemor-
rhage and injury (Fig. 28.1 ). Kuran et al. [ 8 ] com-
pared four different types of osteotomes regarding
soft tissue injury. They found that the injury was less
with the use of narrow osteotomes. Wide osteotomes
may cause more soft tissue injury. But some authors
use wide osteotomes because they believe that due to
complete mucosal laceration, less postoperative
swelling swelling with intranasal bleeding could
result [ 9 ] . When considering the shape of the osteot-
ome body, it was found that performing high-to-low
osteotomy was easier with curved osteotomes than
Fig. 28.1 A 2-mm V-shaped
osteotome
390
R. Tahamiler and M. Yener
straight osteotomes with nearly 40% less atypical
fracture lines [ 8 ] . In another study, Becker et al.
compared 2.5-mm and 3-mm guarded osteotomes to
standard 4-mm guarded osteotome in performing
endonasal lateral osteotomy; cut in a single-pass,
high-low-high fashion, the intranasal mucosa was
inspected for the presence of mucosal injury. They
found that 2.5-mm osteotome was reliable and the
least traumatic to soft tissue [ 5 ] . Also the pyramid
thickness along the osteotomy pathway was mea-
sured and was found to be relatively thin (<2.5 mm).
This fi nding also supported the use of small instru-
ments for osteotomy [ 5 ] . Thomas et al. also con-
cluded that the use of narrow osteotomes during
endonasal osteotomy contributed to a reduction in
the loss of nasal support and postoperative edema
and ecchymosis [ 10 ] . Tardy and Denneny [ 11 ] also
use 2- to 3-mm osteotome, supporting the idea that
narrow osteotomes will maintain periosteal support
and decrease the rate of bleeding, soft tissue disrup-
tion, and scarring. Murakami and Larrabee [ 4 ] ana-
lyzed lateral periosteal disruption and soft tissue
injury by comparing the use of 4-mm guarded
osteotomes for endonasal approach versus 2- or
3-mm unguarded osteotomes for the percutaneous
approach. They found that the percutaneous approach
created more irregular osteotomies but the endonasal
approach produced more soft tissue trauma. Recently
Mottura [ 12 ] described a double-guarded 4-mm
straight osteotome for lateral osteotomy that enabled
separation of external periosteum and mucoperios-
teum while performing osteotomy.
For percutaneous osteotomy, a small (2-mm)
unguarded osteotome is widely advocated.
Some external soft tissue injury is unavoidable,
but it may be controlled by the application of
proper technique and by the selection of a small
osteotome [ 5 ] .
Guarded osteotomes that are used intranasally
produce more bleeding than properly used percu-
taneous 2-mm osteotomes. Regardless of the soft
tissue elevation or the position of the guard,
guarded osteotomes cause more soft tissue
trauma. These kinds of osteotomes produce lin-
ear laceration along the mucosa and cause more
bleeding. Conversely the percutaneous osteot-
omes traumatize the mucosa less, resulting in less
bleeding [ 13 ] .
28.5
Historical Development
Joseph and his trainees popularized the early
technique for lateral osteotomies. In their tech-
nique, they created a subperiosteal tunnel and
used a saw to perform osteotomy, beginning at
the most inferior portion of the pyriform aper-
ture. Then the osteotomy cut was extended
along the frontal process of the maxilla and
ended at or beyond the nasofrontal suture (low-
to-low osteotomy) [ 1, 4 ] . As the saw was caus-
ing loss of height of the nasal bones, the
surgeons began to use osteotomes to perform
an accurate cut. Later the patients were appear-
ing to experience postoperative nasal airway
obstruction due to excessive narrowing of the
nasal cavities with the “low-to-low” technique.
Webster et al. in 1977 [ 14 ] pointed out that a
triangular bone should be left at the pyriform
aperture just superior to the inferior turbinate
and described the curved osteotomy. In this
technique, the osteotomy was starting rela-
tively high at the pyriform aperture, leaving a
triangular bone. Then the cut was extended low
onto the ascending frontal process of the max-
illa and then was curving back high again to
prevent the extension of the osteotomy into the
frontal process (high to low to high). This
modi fi cation of the technique preserved the
airway by avoiding medial displacement of the
lateral nasal walls. Also high osteotomy at the
level of frontal process allowed for the preser-
vation of the frontal process. In the cases with
low osteotomy at the level of frontal process
and infracture of the nasal bones, the radix was
acting as a pivot and the segment beyond the
radix was lateralizing and was creating the
rocker deformity [ 1 ] . Conversely by ending the
osteotomy high and by combining the lateral
osteotomy with a medial osteotomy will avoid
this deformity .
On the other hand, external osteotomy was
performed in 1955 by Goria and was popular-
ized by Straatsma [ 15, 16 ] . The authors who
prefer this technique believe that perforating
technique causes less mucosal tears and less
intranasal complications and postoperative
morbidities [ 17, 18 ] .
391
28 Lateral Osteotomy in Rhinoplasty
28.6
Types of Osteotomies
28.6.1 Incomplete Osteotomy
Incomplete osteotomy is the fracture of the lat-
eral nasal walls without the use of an osteotome.
The fracture is usually performed manually. As
the forces used to make an incomplete osteotomy
are uncontrolled, the osteotomies are less con-
trolled and less predictable. The main advantage
of this kind of fracture is the stability due to
greenstick fracture [ 19 ] .
28.6.2 Complete Osteotomy
Compete osteotomy is the cut on the lateral nasal
walls with an osteotome where all the fracture
lines are cut. Osteotomes accomplish direct
forces and produce clean cuts. The stability after
the complete osteotomy depends on the nature of
the bony interface along the osteotomy line and
on the extent of attached soft tissues [ 19 ] .
28.6.3 Linear (Single Cut) or
Continuous Osteotomy
In this technique, the osteotome is used to make a
bone cut along the nasal facial groove [ 20 ] . The
path of the cut may follow high-low-high, low-low,
or low-high pathway. The osteotomy is done in a
continuous fashion, resulting in smooth cut edges.
28.6.4 Perforating Osteotomy
Using a sharp 2-mm straight osteotome, a series
of perforations are placed along the desired frac-
ture site using a transnasal or transcutaneous
approach. In percutaneous approach, one or two
osteotomy sites are marked on the skin, and perfo-
rations are created through these sites along the
desired osteotomy route. Alternatively, the perfo-
rations can be placed intranasally. The perforating
intranasal osteotomy can also be used to “push
out” the nasal bones that have been medially dis-
placed by previous trauma or surgery [ 20 ] .
28.6.5 Low to High
Low-to-high osteotomy is made from the junction
of the caudal edge of the nasal bones with the fron-
tal process of the maxilla obliquely to the nasal dor-
sum near intercanthal line superiorly (Fig. 28.2 ).
28.6.6 Low to Low
Low-to-low osteotomy is also made from the
junction of the caudal edge of the nasal bones
with the frontal process of the maxilla but courses
along the base of the nasal bone more vertically
and intersects the intercanthal line lateral to the
dorsum. To achieve medial displacement of the
lateral wall, a medial osteotomy must be done by
medial orientation of the osteotome and continu-
ing across the dorsum (Fig. 28.3 ).
28.6.7 High to Low to High
A modi fi cation of classical lateral osteotomies that
is described is to preserve the airway by avoiding
Fig. 28.2 Low-to-high osteotomy is made from the junc-
tion of the caudal edge of the nasal bones with the frontal
process of the maxilla obliquely to the nasal dorsum near
intercanthal line superiorly
392
R. Tahamiler and M. Yener
the medial displacement of the inferior portions of
the lateral nasal wall . The osteotomy is done in a
curved fashion; the cut is started high at the pyri-
form aperture, preserving a triangular bone at the
pyriform, extending low onto the ascending frontal
process of the maxilla, and then curving back high
to the dorsal part of the nasal bone to avoid exten-
sion into the frontal process. The lateral osteotomy
runs from the most lateral point of the pyriform
aperture to a point medial to the inner canthus of
the eye, most commonly in a high-to-low-to-high
path. In practice, this means a starting point
3–4 mm above the base of the pyriform aperture
and adjacent to the head of the inferior turbinate.
28.6.8 Midlevel or Intermediate
Osteotomy
Midlevel osteotomies are generally performed to
straighten nasal bones with signi fi cant convexity
or concavity. These osteotomies may also be per-
formed to correct a deviated nose with one nasal
bone that is signi fi cantly longer than the other
side. The osteotomy is close to the suture line
between nasal bone and the frontal process of the
maxilla. The midlevel osteotomy connects points
between the base of the nasal bone and dorsum at
the pyriform aperture and radix. The osteotomy
is performed in the midportion of the nasal bone,
parallel to the lateral osteotomy. It usually begins
at the midportion of the nasal bone and continues
to the pyriform aperture [ 20 ] . Then the osteotome
is positioned more cephalated and the cut is con-
tinued to radix slightly over the intercanthal line.
The osteotomy is often performed for convexity
or concavity of the nasal bone, and in these cases,
the osteotomy is generally performed at the apex
of the curvature of the bone [ 1 ] .
Intermediate or midlevel osteotomies may be
performed in a continuous or perforating fashion.
While performing the continuous intermediate
osteotomy, the osteotome is placed at the caudal
border of the nasal bone. The osteotomy is per-
formed in a straight and continuous way. The per-
forating osteotomy is performed in an interrupted
fashion. It can be done either percutaneously or
intranasally, depending on the deformity [ 1 ] . The
percutaneous osteotomy is performed for a con-
vex deformity, and the bone is fractured medially.
For concave deformity, the intranasal perforating
intermediate osteotomy is generally performed.
In this technique, the concave portion is dislocated
laterally. The intermediate osteotomy is per-
formed before the lateral osteotomy, which allows
the stability to perform the osteotomy. It is advised
that the intermediate osteotomy should be done
before the lateral osteotomy because the motility
of the bones after lateral osteotomy may compli-
cate the intermediate osteotomy (Fig. 28.4 ) [ 1 ] .
28.6.9 Double Osteotomy
This kind of osteotomy is the combination of midlevel
osteotomy and the low-to-low lateral osteotomy. It is
important that the midlevel osteotomy must be done
before the base osteotomy to perform the procedure
more easily due to stability of the basal attachment
to the maxilla. The midlevel osteotomy should begin
at the midportion of the nasal bone and be continued
to the level just superior to the intercanthal line. As
the base osteotomy continues superiorly, the cut
intersects the cephalic portion of the midlevel osteot-
omy (Fig. 28.5 ).
Fig. 28.3 Low-to-low osteotomy
393
28 Lateral Osteotomy in Rhinoplasty
28.7
Indications of Lateral
Osteotomy and Selecting the
Appropriate Osteotomy Type
1. Repositioning the excessively wide base: The
most common indication of osteotomy is
medial repositioning of the lateral nasal bones
to narrow the base of the bony pyramid and to
close an open roof after hump resection. In
most cases, a low-to-high osteotomy is done
for this purpose. This osteotomy makes pre-
cise and controllable cut on the nasal bone,
producing a smooth line at the base of the
pyramid.
2. Reducing excessive width of the nasal bone
base near radix: To narrow an excessively
wide cephalated bony base of the bony pyra-
mid, low-to-low osteotomy can be used.
3. Reducing excessive convexity or closing an
open roof with a narrow bony base: The lateral
nasal bones are in convex shape in a medial to
lateral direction. In cases with traumatic defor-
mity in one side of the lateral wall (change of
normal convexity to concavity due to trau-
matic fracture), the midlevel osteotomy is per-
formed to the normal side to reduce the lateral
convexity to match the other side.
In a nose with excessive vertical height and
dorsal hump but narrow base, the resection
of the hump would produce an open roof. To
close the roof and to avoid narrowing
of the nasal base, midlevel osteotomy can be
used.
4. Correction of excessive base width and
excessive convexity: Double osteotomy can
be performed to correct the excessive con-
vexity with correction of the base width. In
double osteotomy, a midlevel osteotomy is
combined to a low-to-low or low-to-high
osteotomy [ 19 ] .
28.8
Surgical Approach
The osteotomies can be done via internal or exter-
nal routes. The main advantage of the intranasal
approaches is the absence of an external scar. In
intranasal techniques, more soft tissue elevation
and restriction of osteotome direction by the alar
rim often increase soft tissue trauma. Conversely
the external approach is more fl exible without
any restrictions on osteotome direction. The only
restriction of external approach is the visible scar
on the skin, but this may be minimized with the
use of narrow and sharp osteotomes.
Fig. 28.4 Double osteotomy
Fig. 28.5 Midlevel or Intermediate osteotomy
394
R. Tahamiler and M. Yener
28.8.1 Surgical Techniques in
Endonasal Osteotomies
Lateral osteotomies may be performed in a con-
tinuous or perforating fashion. For continuous lat-
eral osteotomies, a straight or curved guarded
osteotome is generally used. A local anesthetic
should be injected to both sides of the lateral wall
to hydrodissect the soft tissues overlying the bone
and also to assist with hemostasis. Next, a subpe-
riosteal tunnel is created before the osteotomy is
performed. This protects the periosteum from
injury, allowing for decreased bleeding and subse-
quent swelling and ecchymosis [ 1 ] . Also the sub-
periosteal tunnels ensure proper stability after
surgery [ 4 ] . The guard of the osteotome may be
placed internally or externally. When the guard is
placed internally, a submucosal tunnel is created
along the nasal surface of the ascending process of
the maxilla. The guard is placed beneath the
mucosa, which is preserved, and the osteotomy is
performed. This reduces swelling and provides
increased stability of the fragment due to the
reduced injury to the periosteum and mucosa [ 21 ] .
When the guard is placed externally, the osteotomy
may be performed with or without a subperiosteal
tunnel overlying the external surface of the ascend-
ing process. The guard is placed on the external
surface just superior to the inferior turbinate, and
the osteotomy is performed. When the guard is
placed externally, it may be used in a more con-
trollable fashion as the tip of the guard can be pal-
pated as it travels along the path of osteotomy. As
the unguarded edge passes on the mucosal surface,
it can lead to extensive injury to the internal nasal
mucosa, allowing for decreased bleeding and sub-
sequent swelling and ecchymosis [ 1 ] . A small
incision is made in the nasal vestibule at the pyri-
form aperture just above the inferior turbinate, and
the osteotome is inserted. The course of the lateral
osteotomy begins at the level of the attachment of
the inferior turbinate. According to the anatomy
and the results to be achieved, a curved or straight
course or high or low level of osteotomy is planned.
In most cases, a high-low-high osteotomy is pre-
ferred that leaves a small triangle of bone at the
pyriform aperture to preserve the lateral attach-
ments of the suspensory ligaments. This helps to
preserve the nasal airway. After the initial cut, the
osteotomy is continued along the nasal facial
groove until it curves superiorly and anteriorly into
the thinner aspect of the nasal bone at the level
of the inferior orbit. The cut is then terminated
around the level of the medial canthus. If it is car-
ried higher into the thicker bone of the nasofrontal
suture, a rocker deformity may result in which
infracture of the nasal bone results in protrusion at
the superior fracture site [ 22 ] . At the completion of
the lateral osteotomy, the osteotome is turned
inward to complete the fracture and displace the
fragment internally. The back fracture that com-
municates the lateral and medial osteotomies may
be performed as a transverse osteotomy, fading
medial osteotomy, or fracture by digital pressure.
The medial and transverse osteotomy or medial
fading osteotomy is performed prior to the lateral
osteotomy and inward fracture of the nasal bone
fragment. The fracture by digital pressure is per-
formed after the lateral osteotomy and the nasal
bone fragment is then displaced internally.
Periosteal elevation remains a matter of surgeons’
personal preference; most of the authors do not
elevate periosteum or only create a periosteal
tunnel as the overlaying soft tissues may a useful
support for bony fragments, increasing the stability .
Also not elevating the periosteum may decrease
the incidence of air fl ow obstruction and of aesthetic
irregularities [ 23 ] .
28.8.2 Surgical Techniques of
Percutaneous Osteotomies
Perforating lateral osteotomies are the alternative
to continuous osteotomies. Applying some basic
principles in perforating osteotomies can increase
accuracy and decrease morbidities. The smaller
the osteotome, the more effective the cutting
force will be. The soft tissues over the lateral
nasal wall should be elevated properly to avoid
lateral nasal artery branches. The force to perfo-
rate the bone should not be excessive to perforate
the nasal mucosa and enter the nasal cavity. This
precaution decreases the bleeding and morbidity.
With this technique, optimal low-to-high, medial,
low-to-low plus medial, midlevel, and double
395
28 Lateral Osteotomy in Rhinoplasty
osteotomies can be performed. In percutaneous
osteotomy technique, a sharp 2- or 3-mm osteot-
ome can be used. Approximately 7–10 min before
the osteotomy, the entry site and pathway should
be injected subperiosteally along the lateral and
medial aspects of the lateral nasal wall. A punc-
ture is done at the junction of the nasal bone with
the cheek skin along a line continuous with the
nasolabial fold overlying the midportion of the
planned osteotomy with a blade or with the tip of
the osteotome. The skin incision is located mid-
point between the medial canthus of eye and low-
ermost point of the nasoalar groove at the nasal
process of the maxilla. Then the 2- or 3-mm sharp
osteotome is inserted through the incision. The
osteotomy should begin on the midportion of
the osteotomy line just anterior to the junction of
the nasal bone with the maxilla. Then the skin is
lifted and osteotome is put on the nasal bone near
the dorsum and pushed all the way to the bone.
Holding the osteotome against the wall, the
osteotome is slid down to the desired osteotomy
line at its midpoint. This maneuver displaces the
angular artery away from the surgical fi eld. With
controlled mallet forces, cut on the lateral wall of
the nose is created. Then osteotome is retrieved
from the perforated bone and put closely over the
bone again inferiorly to the pyriform aperture.
Interrupted but closely adjacent (2–3-mm) punc-
tures are performed in cephalic and caudal direc-
tions. For more mobility, each puncture may be
combined with each other in a continuous fash-
ion. At the cephalic end of the osteotomy, the cut
is continued across the midline to prevent uncon-
trolled back fracture and avoid triangular spickle
at the dorsum. There is no need to advance the
osteotomy superior to the intercanthal line [ 19 ] .
With gentle manual pressure, nasal bone is repo-
sitioned medially. If the gentle pressure does not
fracture the bone, the surgeon should not apply
force but should fi nd the place resisting the repo-
sition and reperform the osteotome cut on that
point. By doing this, undesirable and uncon-
trolled fractures are prevented.
Cases with excessively collapsed bony pyra-
mid due to previous surgery or trauma can also be
managed by transnasal percutaneous lateral
osteotomy or “inside-out” lateral osteotomy. The
perforations are placed intranasally and the nasal
bones are pushed out to mobilize the nasal bone
laterally and to widen the vault and open the air-
way [ 1, 20 ] . The perforations can also be carried
out with a 2-mm unguarded osteotome. The entry
site is intranasal at the pyriform aperture and the
perforations are made in every 2–3 mm along a
mirror-image pathway.
Tardy and Denneny [ 11 ] described the use of
the micro-osteotome to perform precise endonasal
perforating osteotomies with minimal damage to
the periosteum and intranasal mucosa. Percutaneous
osteotomies do not require mobilization of the soft
tissues, and the osteotomy can be placed exactly to
the desired place. They make it possible to posi-
tion and conduct the osteotome exactly along the
line desired [ 13 ] . Consequently trauma, bleeding,
postoperative ecchymosis, and edema are less, and
due to partial interruption of the periosteum, the
stability is more [ 3, 13 ] . Anatomic and clinical
studies indicate that the external perforated tech-
nique results in a more controlled fracture with
less intranasal trauma [ 3 ] . Because the osteotomy
is perforating, the resulting fracture is of a green-
stick type, which guarantees the stability of the
bone stumps and avoids their sinking [ 24 ] .
Compared with the popular internal continuous
method, the perforated technique preserves
periosteal attachments to the bone, which decreases
the amount of dead space, reduces subluxation and
airway compromise, and provides greater stability
of the bony vault after manipulation [ 25 ] .
The main drawback of the percutaneous tech-
nique is the visible scar on the face. But studies
showed that the external approach was producing
excellent cosmetic results at the puncture sites in
the skin [ 26 ] and the cutaneous scars were virtu-
ally invisible a month after surgery [ 13 ] .
28.8.3 Sequence of Osteotomies
During rhinoplasty, each surgical step must be
done in a sequential manner. The sequence of
the osteotomies will vary depending on the
deformity that the surgeon wishes to correct.
The sequence of the osteotomies is based on
some principles [ 19 ] : For external osteotomies,
396
R. Tahamiler and M. Yener
the osteotomy should begin in thicker and more
stable area and proceed to thinner and less sta-
ble area. For the low-to-high osteotomy, the
most stable portion is the area where the frontal
process of the maxilla unites to the nasal bone.
The pyriform aperture is thinner and the bone
thickness is variable more superiorly. The
osteotomy should begin in the midportion,
extend caudally to pyriform aperture, and return
to the stable area and then to the cephalic por-
tion superiorly. In low-to-low osteotomy, the
same sequence should be followed for the lat-
eral cut. At the cephalic end, the medial osteot-
omy should begin from medial to lateral to join
the lateral osteotomy. When performing double
osteotomy, one should always perform the
midlevel osteotomy fi rst while the more stable
base of the lateral nasal wall is still intact. After
the midlevel osteotomy, lateral osteotomy must
be done [ 19 ] .
In general the medial osteotomy will be per-
formed fi rst as a straight or fading continuous
osteotomy, depending on the surgeon’s prefer-
ences and treatment goals. If an intermediate
osteotomy is required, this is performed after
the medial osteotomy but before the lateral
osteotomy to allow for stability of the nasal
bone during the osteotomy. The lateral osteot-
omy is then performed and the mobilized seg-
ments are placed into the desired position [ 1 ] .
The timing of the osteotomies within the time
frame of the entire rhinoplasty procedure may
vary depending on the surgeon’s preference as
well as the deformity being treated [ 1 ] . In the
case of a severely deviated nose, the surgeon
may wish to perform the osteotomies fi rst to
allow for the midline positioning of the bony
septum and nasal bones, thus allowing for the
ultimate alignment of the middle and lower
thirds from the now midline bony vault. In these
cases, sequence of osteotomies is performed in
the following order [ 1 ] :
1. The medialized nasal bone should be mobi-
lized fi rst with a medial, intermediate (if nec-
essary), then lateral osteotomy.
2. The medialized nasal bone is then displaced
laterally to allow space for the midline reposi-
tioning of the deviated septum.
3. A straight medial osteotomy is then performed
on the opposite side into the nasal root, which
is used as a fulcrum to reposition the septum
in a midline position.
4. The intermediate (if necessary) and lateral
osteotomy is then performed on the opposite
side, and the nasal bone is placed into an
appropriate position.
When the septum is not severely deviated
and the osteotomies are being performed to nar-
row or widen the bony vault without reorienta-
tion, the osteotomies may be postponed to the
end of the procedure. By this way, the surgeon
may apply pressure on the osteotomies, and
immediate splinting of the nose may decrease
the overall edema and bleeding associated with
osteotomies. If the osteotomies are performed
earlier in the case, the surgeon may still hold
pressure to reduce the swelling and bleeding;
however, the resultant edema is inevitable. The
soft tissue swelling may interfere with the sur-
geon’s ability to evaluate the necessary struc-
tural changes that should be made to achieve the
desired aesthetic result. Therefore, it is often
best to delay the osteotomies until the comple-
tion of the procedure whenever possible [ 1 ] .
28.9
Complications
Rhinoplasty is a dif fi cult operation and requires a
three-dimensional manipulation of nasal structures
with limited access [ 27 ] . The outcomes depend on
the surgical skill and some patient factors like skin
and subcutaneous tissue thickness. Generally the
complications of rhinoplasty may be divided as
intraoperative and postoperative complications.
The postoperative complications may also be sub-
divided as early and late complications. Early com-
plications are hemorrhage, hematoma, infection,
periostitis, edema, ecchymosis, skin problems, and
septal perforations [ 27 ] . Late complications gener-
ally involve abnormalities of the nasal tip, cartilagi-
nous vault, and bony vault [ 27 ] . The complications
of lateral osteotomy, especially early complica-
tions like hemorrhage, infection, edema, and
ecchymosis, are the same for all the steps of rhino-
plasty operations, but some complications like
397
28 Lateral Osteotomy in Rhinoplasty
overmobility of the infractured bones are unique to
the lateral osteotomy. Complications associated
with lateral osteotomy are hemorrhage, prolonged
edema and ecchymosis, nasal obstruction due to
narrowing, and aesthetic deformity and asymme-
try [ 2, 3, 14, 25 ] .
Trauma to the intranasal soft tissue struc-
tures like mucosal tears may lead to destabiliza-
tion, bleeding, and prolonged edema and
ecchymosis [ 2 ] . To minimize the trauma from
lateral osteotomy, the selected technique should
be performed with proper osteotomes to main-
tain suf fi cient mucosal and periosteal preserva-
tion [ 2 ] . Intraoperative injuries to the nasal
tissues are uncommon [ 28 ] . Excessive destabi-
lization or improper replacement of the frac-
tured bones may result in collapse of the nasal
bones, causing visible asymmetry and defor-
mity. Adjacent internal valve collapse nega-
tively affects the airway. If this is noted, an
elevator should be used to replace the bones to
their appropriate position [ 28 ] .
Bleeding is the most common postoperative
complication of the rhinoplasty operations. This
usually occurs either during the fi rst 48 h or at
10–14 days postoperatively. Some precautions
before and during the operation may decrease the
risk of postoperative bleeding. Aspirin and any
herbal supplements should be discontinued 10 days
before the procedure [ 29 ] . Preoperative injection
using local anesthetic mixed with epinephrine into
the subcutaneous tissue and topical oxymetazoline
or cocaine application on the mucosa may decrease
intraoperative and postoperative bleeding risk. Also
dissection in the correct tissue planes, that is, main-
taining dissection in the submucoperichondrial
plane, avoids reaching the nasal super fi cial muscu-
loaponeurotic system (SMAS) [ 28 ] . Bleeding is
most likely to occur at the trans fi xion incision or
anterior septal mucosal incisions. Proper closure of
these incisions at surgery will minimize this com-
plication [ 27 ] . The second most common time for
postoperative bleeding occurs from the 10th to 14th
day, most likely because the maturing clot sepa-
rates from the incision. If the bleeding occurs from
the anterior nose, the exact point should be identi fi ed
and treated using direct vision. Early light bleeding
can be managed by either oxymetazoline, or ice
with digital pressure, or a combination of both [ 28 ] .
Severe bleeding may require anterior and poste-
rior nasal packs. Persistent bleeding may rarely
require hospitalization and treatment in the oper-
ating room [ 27 ] .
Hematoma at the nasal dorsum may displace
the nasal tissues, can produce excessive scar tis-
sue, and affects the normal healing mechanisms.
Hematomas of the dorsal skin can also be pro-
duced during removal of the cast. Septal hemato-
mas may occur after rhinoplasty operations that
can cause nasal blockage and septal perforations
if not treated properly [ 27 ] .
Infection after rhinoplasty operations is rare.
The patient will typically present with regional
erythema and cellulites. This condition should be
differentiated from allergic reactions and proper
antibiotics should be started. Abscesses are also
rare. Small and localized abscesses can occur
along the incision lines or in areas where surgical
debris has collected, and can be treated with inci-
sion and drainage along with appropriate antibi-
otics [ 27 ] . The most frequent organism causing
these infections is Staphylococcus aureus , and
antibiotics like trimethoprim/sulfamethoxazole,
clindamycin, or levo fl oxacin can be used for
treatment [ 30 ] . Toxic shock syndrome has been
reported in cases of nasal packing. As the cavern-
ous sinus is very close to the operation site, basal
meningitis may develop rarely [ 31 ] .
Edema and ecchymosis following rhinoplasty
are the expected consequences. The amount of
swelling usually depends on patient factors and
may be reduced by using steroids perioperatively.
Generally edema resolves within 6–12 months,
and the fi nal result may be appreciated [ 29 ] .
Following lateral osteotomies, the incidence of
periorbital edema and ecchymosis is high and
may last for 2–4 weeks. The use of a smaller
unguarded osteotome may decrease this compli-
cation [ 11 ] .
Deformities on the bony vault can be noted
after lateral osteotomies. Improper placement of
the osteotomy along the lateral nasal wall may
lead to complications. A low osteotomy may cause
nasal obstruction when the fragment is displaced
medially into the airway [ 1 ] . A high osteotomy
that is placed above the thick nasofacial sulcus
398
R. Tahamiler and M. Yener
may become palpable and visible under the thin-
ner nasal skin that is located above the sulcus [ 1 ] .
An incomplete osteotomy may result in incom-
plete displacement of the nasal bones and may
cause deviation of the bony vault [ 1 ] . Following
lateral osteotomy, hyperostotic bone may form
usually due to improper elevation and tearing of
the periosteum along the osteotomy [ 1 ] .
If the osteotomy is carried into the frontal pro-
cess and the nasal bones are infractured, the seg-
ment beyond the radix may lateralize, causing the
rocker deformity [ 1 ] . To solve this problem, a
percutaneous transverse osteotomy should be
performed to move the nasal bone independently
of the nasal root [ 1 ] .
Excessive elevation of the soft tissues beyond
the osteotomy line may cause overmobility of the
fractured segment and may lead to dif fi culty in
maintaining position. In these cases, percutaneous
sutures and a piece of Merocel from the nasal
cavity may secure the fl ail segment [ 1 ] . Damage to
intranasal mucosa may result in synechiae between
the lateral nasal wall and the septum, causing nasal
obstruction. These adhesions may be split and a
piece of Silastic may be placed for 2–3 weeks to
prevent re-formation of the synechiae [ 1 ] .
Conclusions
Lateral osteotomy is the crucial step in rhino-
plasty that must be executed correctly. Unequal
and improper lateral osteotomies may lead to
asymmetry of the bony vault, open roof defor-
mities, and persistent bony ridges. Maintenance
of a periosteal layer is critical in splitting
mobile nasal bones and camou fl aging minor
bony irregularities. Many different osteotomes
have been offered so far for lateral osteoto-
mies, but we think that V-shaped 2-mm osteot-
omes reduce the risk of postoperative edema
and ecchymosis and guide up cephalically to
the medial oblique osteotomy with the best
cosmetic results. The authors suggest low
curved osteotomy line without periosteum
elevation, the use of micro-osteotomes, medial
oblique osteotomies, and bone cuts rather than
fracturing in lateral osteotomies.
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