Mastering Revision Rhinoplasty 0387989048, 9780387989044

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MASTERING REVISION RHINOPLASTY

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[III lis, 1

MASTERING REVISION RHINOPLASTY Springer

Michael Evan Sachs, M.D. Surgical Director Sachs Institute for Facial Plastic and Reconstructive Surgery 128 Central Park South New York, NY 10019 USA [email protected]

Illustrations by Alan Nahigian Design and page make-up by A Good Thing, Inc.

Library of Congress Control Number: 2005929230 ISBN-10:0-387-98904-8 ISBN-13:978-0387-98904-4

Printed on acid-free paper.

© 2006 Springer Science-i-Business Media, Inc. All rights reserved.This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science-i-Business Media, Inc., 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed in the United States of America. 98765432 1 springer.com

(AGT/WW)

To my mother Celia who inspired in me a thirst for knowledge and exploration To m.y father David who taught me to always do my best and expect nothing less To my wife Linda my best friend and foundation, who guides me through life and continually shows me the true meaning of love To my children Blake, Courtney and Steven whose boundless creativity, insight, and wonderfully optimistic view of life continue to inspire my view of humanity And to all my courageous patients a very special thank you for your boundless confidence, trust, and support: without you, this book would not exist

The practice of surgery is at first glance a very personal and intimate profession. It is essentially one surgeon affecting the visage of one patient through the use of one's hands. Deeper analysis reveals however an entire team of individuals who help make this process rewarding and successful. Firstly is the partner in the intimate setting of the operating room, the operating room nurse.This person is a critical component in guiding, enlightening and aiding the surgeon. I have been blessed to have had for the past twenty years, a most ingenious and gifted nurse, Liza Uy. Liza has helped me perform the most difficult and yet the most gradify^ing of surgeries over the past years. Her infinite skill and judgement has helped to turn the most difficult case into a work of art. I cannot thank Liza enough for her years of service to me and my patents. I hope that her experience with me has been as fun and gratifying to her as it was for me. The next member of the team who is equally responsible for the success of my practice and the comfort of my patients is Lillian Guido. Lillian, who has been with me for almost 15 years, is the epitome of quiet grace and streamlined efficiency. My patients and I are both lucky to have her help us with the myriad tasks which she performs flawlessly. I am endebted to Lillian for all her years of tireless and selfless service. Theresa Wiatroska has worked tirelessly for over 15 years, contributing dearly to the health and welfare of my patients. She has taken care of all the needs of our office staff in a cheerful and caring manner.We are all indebted to theresa for her service. Although there are many other members of our team that have contributed to the happiness and health and welfare of my patients through the years, the person who has kept the office together by helping out in any way possible for more than twenty years is Rosa Giammarco. Helping, listening, and guiding the patients through all the steps of their surgeries, she has been the most compassionate and efficient of office managers. I often tell my patients that Rosa gets more letters of thanks for her delightful and wonderful "way" than anyone else in the office. Simply said, without Rosa the office would not be the loving compassionate place it has become. VII

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r nnnI-U- 11 T 1

PART l

Chapter Chapter Chapter Chapter Chapter

1 2 3 4 5

PART 2

Chapter 6 Chapter 7 Chapter 8 Chapter 9 Chapter 10 Chapter 11 Chapter 12 Chapter 13 Chapter 14 Chapter 15 Chapter 16 Chapter 17 Chapter 18 Chapter 19 PART 3

Chapter 20

[ uUII

1

Introduction

xi

PHILOSOPHY/PLANNING/ART

1

Philosophy of Successful Revision Rhinoplasty Planning Differences Between Revision and Primary Rhinoplasty Aesthetics The Peri-Operative Setting TECHNIQUE

3 7 13 .15 17 19

The Preservation and Restoration of Nasal Function Bony Nasal Vault Middle Nasal Vault Septum . . Columella Internal Nasal Valve Reconstruction Nasal Rotation Transition Zones Nasal Lip Complex Tip Introduction and Anatomy Tip Medialization Nasal andTip Projection Total Tip Reconstruction Titanium Nasal Reconstruction

21 53 77 107 117 137 149 179 197 207 211 243 287 301

WORKSHOP

323

Case Examples

325

Index

387

IX

1 ¥\ T" r\ / \ r\

iiPTinn UullUII

Mastering Revision Rhinoplasty is a compendium of ideas that have been formulated during the past twenty years. These years encompass more than thirty five thousand primary and revision rhinoplasties, the sum experience that have been analyzed in an attempt to categorize and clarify the technically and aesthetically challenging sub-specialty of Revisional Rhinoplasty. During this analysis certain basic themes began to emerge, which allowed me to organize the book in a manner, which when followed carefully will allow the experienced rhinoplastic surgeon to adequately handle most of the common problems associated with Revisional Rhinoplasty. It is commonly thought that Revisional Rhinoplasty is very difficult not only to perform, but also to accomplish successfully. Thus this art form has been shrouded in mystery and for the most part has never really been associated with much enthusiasm or promise of excellent or even good results. While reading this book it will become obvious that indeed many revisional rhinoplasties are relatively easy to accomplish, as one begins to realize the basic mistakes that led to the initial failure. It is indeed interesting how many major deformities fall into very specific and set categories or collections of mistakes, and when analyzed fully, can be dependably fixed, and hopefully in the future avoided. It is axiomatic that the more one learns about Revisional Rhinoplasty the better one's primary rhinoplasty results become. It is certainly impossible for all primary rhinoplasties to turn out successfully. However, it is true that a large percentage of these failures can be repaired immediately following the incident. It is therefore, my fervent hope and wish, that by mastering these techniques, most primary revisions can be performed intra-operatively thereby obviating the need for a secondary revisional surgery. One can almost state that the true purpose of this book is to abolish the need for revisions by hopefully avoiding the error in the first place, or secondarily allowing for an intraoperative revision at the time of the primary rhinoplasty.

XI

XII

Mastering Revision Rhinoplasty

Thus my true impetus for writing this book stems from a desire to see Revisional Rhinoplasty become an integral part of the primary procedure, thus improving the aesthetic and functional results of this most intriguing procedure. Rhinoplasty is an art as well as a science, and although one might possess the technical prowess to successfully finish the operation, it is the intrinsic artistic expression of the surgeon that dictates natural from artificial; beautiful from ugly, and success from failure. As one would practice a technical skill, the truly successful surgeon appreciates the artistic aspects of this surgery and consciously develops this appreciation, methodically incorporating the two disciplines into a cohesive force. This combined artistic and scientific force over time will grow and strengthen if the surgeon is open to new ideas of form, function, art and expression. The book of course will serve many purposes. As one reads the book and learns various techniques for repairing problems, the thinking surgeon will critically examine one's own techniques, subsequently modifying and improving them, thereby enhancing one's ability to perform primary rhinoplasty. It has become abundantly clear during the preparation of this book that certain mistakes, are made repeatedly. Some of the mistakes are technical in nature, either iatrogenic or secondarily due to some problem occurring during the very delicate healing process. Most however, are due to an aesthetic mis judgment, which leads to an unnatural, operated look. Some of these results are almost expected because the very nature of the operation initially was designed to offer unnatural results as a matter of course. The developers of this fascinating operation were offering patients, a change in ethnic image and identity and not an aesthetically beautiful and natural nose. This however is no longer the case. Rhinoplasty has crossed all ethnic lines and cultures and is now designed not only to change the nasal visage, but also to do it in a more secretive way. Cosmetic surgery today mirrors the fashions and attitudes of a generation that demands natural as a definition of beauty. Natural is what we should strive for in the primary operative setting, however it is essential in a revisional setting. One could actually define Revisional Rhinoplasty as the process of naturalizing an artificial nose. This book is designed to present a variety of techniques that have proven successful. It is most definitely not a compendium of all techniques on revisional plastic surgery. It is very much a personal approach to the complicated and diverse problems that present themselves. The genesis of many of the techniques discussed emanate from a dissatisfaction with previously published procedures which I feel do not have a high enough index of success to be used routinely. I have included techniques in this textbook, which have predictably and reliably been used over the last 20 years to solve the basic as well as the unusual problems that occur during Revisional Rhinoplasty. Thus this book should be viewed as an attempt to systematically categorize post rhinoplastic problems, which are in need of revision. It will become readily obvious how limited a number of specific groups can be defined which concern functional and aesthetic deformities of Revisional Rhinoplasty. The book is

Introduction

XIII

designed to be read section by section in the order in which it is presented. I would then recommend a re-reading of the first section so that the tenets laid down in this area are more readily understood after having experienced the technical presentations. The serious student will then utilize the book as an atlas of techniques that can be conveniently referenced when needed in any particular situation. All surgeons should then use any new information as a beginning platform of information from which to develop and refine their own experience, collecting and analyzing their own personal library of techniques, as they advance though this most wonderful and satisfying Discipline.

PHILOSOPHY/ P LAN NIN G/ART

iil PHILOSOPHY OF

REVISION

SUCCESSFUL

RHINOPLASTY

CONFIDENCE The key element necessary to succeed in any endeavor is confidence. This is observed very obviously in sports like tennis and in technical skills like shooting. However, in surgery in general and in revision surgery more specifically, the element of a confident surgeon is paramount to the successful completion of the operation. The confidence factor of a surgeon is, of course, determined by many things. Most surgeons are inherently confident. However, the supreme confidence necessary to complete a difficult and challenging revision rhinoplasty must be meticulously acquired. Initially, confidence is gained with experience, supplemented by reading, direct observation, and studying videos. Additionally, students of revisional rhinoplasty will embark on a self-designed course of lifelong duration, which will enable them to continually evaluate the results of surgery and alter and upgrade their techniques, so as to continually improve the scope and success of their endeavors. This line of study must of necessity start at the very beginning; thus the prudent student will initially attempt to do only those cases that, for want of a better term, are "easy." Re: A bump left on the dorsum. As experience and confidence grows, tip surgery and then combinations can be tried. Do not get discouraged. The lessons from failure can probably be more beneficial to the educational process than those from success. The key, however, is constant monitoring and lifelong vigilance of results and techniques. This requires a system of documentation that encompasses the preoperative diagnosis, the intraoperative findings, and the actual surgical techniques used. The most important aspect, however, is the ongoing evaluation of the postoperative course of the patient, which should go on for the life of the patient. This documentation should also be as graphic as possible, since words alone are usually not sufficient enough in this genre of surgical record keeping. As the confidence of the surgeon increases, the patient senses this, and in turn his or her confidence in the surgeon concomitantly rises. With this increases in respect, the surgeon now has a more compliant and controllable patient. This transference is absolutely necessary to successfully carry out the planned procedures and all the myriad instructions that the patient must adhere to for his experience to be successful. Confidence also enters into both the actual planning and the technical part of an operation. There are certain maneuvers in revisional rhinoplasty that are technically challenging but necessary. An example of this might be to undermine the

Mastering Revision Rhinoplasty dorsal skin overlying a misaligned graft. The skin is thin and delicate and made even more so by the pressure of the implant. One must have enough confidence in one's ability to undermine this skin without perforating the delicate tissue. If one has confidence in his abilities, then success is the rule; if not, then the operation is doomed to failure.

CONTROL OF OPERATIVE FORCES In every surgical procedure, there are interacting forces that very definitely determine the outcome of an operation. It behooves every surgeon not only to be aware of these diverse forces but also to respect, analyze, and control them if possible, so that they work together to favorably influence and enhance the surgical result.

SURGEON The key forces of any surgical experience are primarily related to the surgeon, his particular training, experience, and, of course, skill. The surgeon who wants to start performing revisional rhinoplasty must embark on a self-designed learning program that allows the surgeon to continually monitor the success or failure of the previous operative experience, while systematically learning and advancing through the multitude of steps of revisional surgery. As the surgeon becomes more experienced and more skillful, his decision making, preoperative diagnosis, and intraoperative technique will improve as well. Inherent in this program is the willingness either to delay performing a certain revisional procedure until greater expertise and experience are garnered or to refer the rhinoplasty to one more experienced. It would be appropriate for the referring surgeon to watch the procedure so as to expand his wealth of knowledge. Of course this is a lifetime commitment that grows with the individual. The rewards are great and well worth the effort. Other factors that are easily controllable and substantially affect the outcome of the surgeon's performance are to schedule very few cases on the surgical day in question. Obtain the best possible and most experienced OR nurses and prepare them in a team approach, going over with them what might be anticipated in the surgery and the need for special equipment or supplies. It is also vitally important to have an atmosphere of commitment and openness among the operating team. Everyone should be allowed to contribute new and innovative ideas that may indeed enhance the performance of the entire team. Failures or mistakes or poor outcomes should be openly discussed with the team during regularly scheduled meetings, in the hope that future mistakes can be avoided.

Philosophy I Planning I Art

5

PATIENT The patient also must be in prime condition both physiologically and nutritionally before the surgery. Baseline lab parameters must be in order, and a preoperative regimen of vitamin and mineral therapy should be instituted. If the patient has some underlying problem such as diabetes or thyroid, then this should be controlled and stabilized.

TEAM: R E A L I S T I C P R O C E D U R A L G O A L S The primary goal of revision rhinoplasty is the attainment of a properly functioning yet beautifully appearing nose. The operation is a series of interrelated steps, each with its own intrinsically defined limitations. The surgeon cannot expect, and the patient must be educated to realize, that certain defects are not within the realistic scope of the operation. Misinterpretation of this tenet will result in failure. To ensure a result that is mutually satisfactory to the patient and the surgeon, the limitation not only of the final result but also what will be accomplished at each stage must be fully comprehended.

illDl PLANNING

Successful revisional rhinoplasty begins by the surgeon's carefully analyzing all the parameters relating to the operation and organizing them into a planned sequence of diagnosis (the problem), treatment (correction of the problem), staging (amount and sequence of surgery necessary to complete the task), and timing (occurrence and interval of planned surgeries).

DIAGNOSIS Although the distinction is often arbitrary, subdividing the formulation of a diagnosis into functional and aesthetic categories will help clarify the thought process. Thus, for example, a diagnosis of tip deformity due to the overzealous excision of tip cartilage would be included under an aesthetic diagnosis. If however the scar secondary to this excision disrupted the functioning of the nasal valve, then the diagnosis of nasal valve stenosis secondary to scarring should also be placed under the functional category. A sample of this analytic outline follows. Completion of this outline includes various treatment steps to consider for each individual problem.

Functional Diagnostic Categories Anatomic boundary

Disease process

Septum cartilaginous bony

deflection deviation

Nasal valve

scarring/subluxation/collapse

Bony pyramid

nasal bone fracture/displacement collapse into pyriform aperture

Columella

deflection/scarring

Tip alar crura (feet)

twisted/collapsed displaced/widened

Mastering Revision

Rhinoplasty

Aesthetic Diagnostic Categories Upper third (bony deviation/contour deformity pyramid) subluxation Middle third upper lateral cartilage contour deformity/scar/twist/subluxation/collapse dorsal septum deflection/contour deformity Lower third tip cartilage twist/collapse/malalignment/asymmetry soft tissue asymmetry/scarring

TREATMENT After the surgeon lists the functional and aesthetic problems with their respective treatment modalities, it is then time to incorporate the two separate surgical lists into an overall therapeutic plan. This one step is probably the most difficult part of the entire scheme and the one that most dramatically spells success or failure. Initially, a complete list of all the various treatment modalities will be formulated for each diagnostic entity. Then the list is coned down to eliminate duplicity of action; Re: one surgical maneuver that will correct more then one problem. For example, if the dorsum is too high, and there is a contour deformity in this same area, then a simple rasping of the bony dorsum will take care of both problems in one step. A step-by-step list of each part of the operation—^with routes of exposure, etc., taking into consideration—^will be designed and act as the framework for the overall reconstructive effort, taking into account the most direct, efficient, and least traumatic approach to each problem.

STAGING Staging is basically a function of matching the extent of damage with the necessary reconstructive efforts needed to ameliorate the pathology.

DAMAGE ASSESSMENT There are several factors related to staging that must be discussed.

I. Extent of damage. How much damage have the nasal tissues endured, and to what extent? Certain issues that directly impact the staging decisions are (1) How many previous surgeries were there and (2) over how much time? Multiple operations are generally more damaging, but another consideration is what interval of time was allowed to pass between surgeries. When evaluating the level of destruction, use the guidelines of diagnosis already discussed, and don't concentrate that much on the number of surgeries. For instance, one very destructive surgery is far worse

Philosophy I Planning I Art

9

then a multitude of partially finished surgeries that don't destroy too much tissue. Which particular tissues were damaged, and how compromised are they? Re: the bony areas can withstand far more trauma then the cartilage or the delicate skin. Anoxia of tissues is also important to assess. Make sure to examine areas with poor blood supply, especially with patients with diabetes or heart disease. Areas that have been previously grafted or irradiated need particular inspection. Assess whether or not tissue has been compromised in an area of the previous implant. Look for areas of pressure necrosis or partial anoxic necrosis.

2. Support mechanisms. The integrity of the support mechanisms must be carefully evaluated. Finally the amount of surgery in each procedure and the exact sequence is planned. All of these parameters can of course change, depending on the various factors already discussed. It is, however, advantageous to have a completed game plan at the onset. Winging it, so to speak, is fine if it is done in a controlled fashion. Winging it in a milieu of let's see what happens can only spell disaster. Basically, the staging part of the planning process identifies all the steps and maps them out.

STAGING TENETS Establish support mechanisms first, then build the aesthetic and functional reconstructions on this stabilizing platform. For example, the diagnosis is (1) malformed tip due to excessive and asymmetric removal of tip cartilages and (2) severely deflected caudal septum. Due to the lack of support that correction of the anterior caudal septum would result in, it is mandatory to establish this support in this particular example because the tip cartilages are going to need this to maintain their structural and, thus, aesthetic integrity. The best plan of action would be to totally correct the caudal septum in one stage and then, at a second stage, correct the tip. The ideal revisional procedure is one that accomplishes all the repair in one stage. This, however, is very rarely the case, since most revisional strategies incorporate at least two separate procedures. When evaluating the staging process, it is best to err on the conservative side and schedule one additional surgery than to do too much in one setting. Once a revisional course has been charted, it is necessary to keep advancing and improving. If the already damaged tissues are pushed too much and too far, then the subsequent operation will fail. It is much better to proceed at a little slower pace, all the while improving the function and aesthetics of the nose.

TIMING The timing of a routine surgical procedure usually does not impact the outcome of the operation. In revisional rhinoplasty, however, timing is such a critical factor that it is necessary to analyze all aspects of this issue.

10

Mastering Revision

Rhinoplasty

The overriding concept in planning revisional rhinoplasty is basically to wait until such time as all or a large part of the healing has been completed. At five years postoperatively, one can assume that the healing is complete; Re: the edema is minimal and the scar tissue present will not misbehave if intervened with again, and the nasal tissues can be relied upon to heal spontaneously and effectively. It can also be assumed that the area is healthy and that a good blood supply is established. Practically, two years is usually long enough to wait before considering a significant amount of revisional surgery. A minimum safety factor before contemplating a revision would be one year. These time limits are not arbitrary; they are directly related to the diagnoses, which in turn cannot be made until all the edema has subsided and one can examine the fine points of the nose, so that an accurate preoperative diagnosis can be made and a specific operative plan developed. Most noses needing revisional rhinoplasty tend to get worse with time: As the swelling diminishes the technical errors become more obvious. The individual's ability to rid itself of this edema is varied and relates to sex, age, skin texture, nutrition, smoking and alcohol consumption, and amount of trauma. Once all the errors of the previous surgery manifest themselves, then the diagnostic plan can be initiated. The second timing tenet is to wait a sufficient period of time for the nasal soft tissues to recover from the trauma of the previous surgery or multiple surgeries. This allows for reestablishment of the critical blood supply that is necessary to prevent necrosis and subsequent infection. When performing revisonal rhinoplasty, the tissues undergo stress due to manipulation and pressure. The blood supply must be at least adequate to withstand these maneuvers without breaking down. The third tenet is to allow the scar tissue to calm down and to perform the operation with a minimum of trauma, so that the scar tissue already present does not become overly aggressive and proliferate, thereby camouflaging the subsequent repair. Although physiologically identical, a more practical way of looking at the same problem is what I refer to as a "softening" of the nasal tissues. This is very much location dependent; Re: the tissues in the upper third of the nose usually do not present this sort of a problem, whereas a tip that has been multiply surgerized has tremendous difficulty in softening and redraping itself after repair. Massage and intralesional steroidal therapy are helpful in accelerating this process. Much more detailed analysis of these factors will be discussed in the technical section. In general, a year is the beginning safety point to start when considering a reoperation. This of course is quite variable, and if indeed there is a problem that must be corrected immediately, then of course this must be dealt with. These might include an I&D of an infected implant, or when cartilage or bone is severely distorted and is compromising the viability of the overlying soft tissue and skin, or when a severely twisted nose is completely blocking the airway. Timing of multiple revisions is another more complex issue. Usually it is best to time revisions no sooner than three months apart. The reason this time frame can be shortened once the revisions are under way is that the assumption is that the staging and planning of the revisions are so well conceived that one procedure does not interfere with the blood supply of the subsequent surgery, or at

Philosophy / Planning /Art

11

least interference is minimized. This can be accomplished by limiting the extent and location of incisions and dissection to minimize the interactions with scar tissue and subsequent surgical planes or areas. Example: As mentioned earlier in the case of a total removal and reconstruction of a tip with a caudal anterior deflection of the septum, one would design the surgery of the septum first, so as to support the tip, and also design the septal incisions so that they do not compromise or cross over the incision areas that will be utilized for the tip reconstruction.

INTRAOPERATIVE PLANNING Intraoperative planning is the logical extension of the very deliberate preoperative process that initially analyzed and subsequently mapped out a strategic surgical plan. This intraoperative process is best conceived as a kinetic system of surgical decision making. A surgical procedure as defined in its most abstract form is a series of discrete interrelated steps, each one designed to correct a component of the overall pathology. Often, the exact sequence is not critical; however, at other times the exact next step is crucial to the outcome. It is important when performing complex revisional procedures to consider the overall plan but to never lose sight of the theoretical end point of the operative sequence, the final aesthetic, and functional result. The actual operative sequence should remain kinetic. The decision-making process should be logical but exquisitely adaptable. The completion of one maneuver opens up a constantly varying array of alternative steps or options that the surgeon may consider. Thus I have compared this type of surgical reasoning to a "forking path." During this type of operative sequencing, a surgeon can travel down any number of constantly forking paths or directions. The operation then becomes a living, kinetic, ever-changing entity, instead of a column of preordained and immutable steps. It is this type of intraoperative thinking that allows for the utmost in flexibility and creativity, and for a balanced series of alternative maneuvers that precisely match the ever-changing spectrum of pathology that is presented to the surgeon. Thus, it is fruitless to hang up beautifully prepared preoperative photos on the operating room wall and to constantly refer to them as if they were the Rosetta stone. Once the first incision is made in the nose, the pictures become almost worthless in an intraoperative setting. In fact, I'm quite sure that they hinder the overall direction and decision-making process by interfering with the thought process and distracting the surgeon by continually referring to a point of reference that has passed, instead of the pathology that presents itself. It would be much more advantageous to show a photo of the ideal nose for this particular patient than the preoperative one. The surgeon would then be continually striving for the perfect next step to achieve a successful result. This surgeon is aware of the changing structure between the step before and the future next step, as well as how the nose changes to itself and to its proportional relationship with the face.

12

Mastering Revision Rhinoplasty

INTRAOPERATIVE CONSIDERATIONS Because of the scarring and fibroblasts already set up in the nose from the previous surgery, the surgeon must use every effort to control the situation and limit further damage to the nose, while at the same time fixing the problem. Extra careful handling of the tissues is always recommended, but the surgeon must find ingenious ways of minimizing total trauma to certain areas of the nose. This is best accomplished by planning the location and extent of incisions. Often times, limited incisions can accomplish the task at hand without reincising into previously operated areas. Scar tissue itself can be sculpted; however, this is a relatively unpredictable technique and should be used sparingly.

^iDl D I F F E R E N C E S B E T W E E N R E V I S I O N AND PRIMARY R H I N O P L A S T Y

HEALING FACTORS In general it takes as long as two full years for most of the healing process in rhinoplasty to subside enough so that a revision can be optimally scheduled. The operative word here is of course optimal. It is unfortunate but true that so many factors enter into rushing a revision prematurely that most of the time, a two-year wait is theoretically good but practically impossible. Most of the time either the patient or the doctor, or both, are so hurried and desirous of a quick fix to a problem that months instead of years is all the time that is allowed to pass. I would say as a rule of thumb that at least six months should be the lower limit for timing a revision, and only in unusual circumstances that will be thoroughly discussed below. Scar formation is one of the many, but certainly one of the most important, factors that have to be considered. Wound healing in the nose is not that much different from traditional wound healing elsewhere in terms of fibroblastic proliferation and collagen formation. However, two conditions are unique to the nose. One is the fact that the surgeon must see the conditions that are being repaired. There is a certain amount of camouflage that is inherent in the actual healing process. The second is that the nose is a unique blend of diverse types of tissue (bone, cartilage, fat, muscle, dermis, and epidermis), all of which heal at different times. Each area must be evaluated carefully before revisional work can be considered.

LIMITATIONS SET BY PREVIOUS OPERATIONS The main limitation imposed by a previous operation or series of surgeries is the loss of important anatomical and structural tissues. Some of these tissues. Re: cartilage, can be readily replaced with autogenous sources, but they never match u p to the original in terms of blood supply and, thus, longevity. The ever-important soft tissue envelope is also easily damaged during previous surgeries, with the loss of blood supply and scaring that can cause eventual necrosis, of utmost importance to diagnose and consider during the preoperative planning stages. Technical errors caused by previous surgeons can be categorized into destructive elements that are the most deleterious and errors of omission. The latter

13

14

Mastering Revision Rhinoplasty errors can be considered as unfinished steps in an otherwise successful operation. The revision of these kinds of "mistakes" are easily remedied. Destructive errors are, of course, more considerable and will require significant planning and execution to correct. Most of the technical errors will manifest themselves as anatomic and structural defects. Equally important is to consider the loss of intrinsic proportion of the nasal tissues that these destructive elements tend to change. An example of this is seen if the upper bony dorsum is too aggressively removed. This throws into disproportionality the entire lower third of the nose, including the tip. The revisional surgeon must thus evaluate the tip of the nose in proportion to the rest of the face, and not just the upper third of the partially destroyed nose. Lastly, the timing and absolute n u m b e r of previous surgeries impacts greatly on what revisional steps can be taken to correct the problems at hand. It is often the responsibility of the revisional surgeon to tell the patient that in fact not all the problems can be corrected but that a certain percentage of improvement is all that can and will be made. Trying to work "miracles" will only lead to disappointment and failure.

CHPlft AESTHETICS

PRIMARY AESTHETIC

CONSIDERATIONS

It has been well documented over the past several decades what parameters make a nose attractive. The key concepts here are proportion. Each element of the nose should be proportional to the other intrinsic parts of the nose and blend smoothly from one anatomic region to the other. Secondly and just as importantly, the entire nose should fit the proportions of the face. The surgeon should not only consider facial features such as lips and eyes and cheek bones but should also be aware of the general shape of the face (oval, round, triangular), the size and relative location of the ears, the height and shape of the forehead, and, of course, the shape and projection of the chin. It is thus important to leave the entire face undraped and ready for intraoperative visual inspection.

SECONDARY

AESTHETIC

CONSIDERATIONS

The goal of the revisional surgeon is to recapture the natural look of the nose, even at the expense of making the nose more beautiful. In general, natural and beauty go hand in hand, and a natural or unoperated-looking nose is probably the best-looking nose for that particular patient. There are times however when, for example, a slightly more bulbous but naturally contoured nose will fit the image of a natural or unoperated look than a tip that is too sculpted, too thin, and "unnatural."

AESTHETIC

L I M I T A T I O N S OF T H E R E V I S E D

NOSE

Although one strives for anatomic perfection during revisional rhinoplasty, it is often painfully apparent that restoring the nose to this level is impossible. The revisional surgeon must accept this de novo and work to achieve the best possible outcome, even though it may fall short of the patient's expectations. The surgeon must always strive for realistic goals, so as to ensure at the very least an improvement, and never plan too much too quickly, which will surely end in making a bad nose even worse.

15

16

Mastering Revision Rhinoplasty

AESTHETICS OF ETHNICITY The artistic surgeon will appreciate the beauty of all races and not try to mold ethnic diversity into one type of "ideal" nose. Each region of the world accepts a standard of beauty based on the particular genetic predisposition of that area. The revisional surgeon must be particularly aware of the various types of natural noses and try to repair the nose into an ethnic equivalent. Thus, for example, the Asian nose that is too low at the bony dorsum should not be raised to a height equivalent to the average Caucasian bridge. The astute surgeon will study ethnic anatomic diversity and tailor the surgery appropriately.

T H E AESTHETICS OF OPTICAL ILLUSION For want of a better term, the nose undergoes many changes during an operation that can only be described as optical illusions. There are many different examples of this phenomenon, and with each individual patient there are variances. One of the many examples of a typical optical illusion that the surgeon must be aware of is that which occurs when the bony and cartilaginous dorsum is lowered. Invariably, in such cases, the nose looks as if it has upwardly rotated. If the surgeon is unaware of this phenomenon and then further upwardly rotates the nose directly, the result will be an overly upwardly rotated nose. Another example occurs when the caudal edge of the columella is reduced. This tends to give the impression that the nose is downwardly rotated. There are of course other examples of this phenomenon, which will be illustrated throughout the text.

(Hi T H E PERI-OPERATIVE S E T T I N G

PREOPERATIVE C A R E Needless to say, the patient should be in the best physiological state that is possible before any revisional surgery is attempted. All metabolic function should be adjusted appropriately, diabetic treatments should be fine tuned, and hormonal therapies should be evaluated. Full medical clearance is essential for anyone over 50 years of age, if performed under local twightlight anesthesia, and there should be no local areas of infection on the face.

INTRAOPERATIVE C A R E The tissues should always be handled with the utmost delicateness and gentleness to avoid trauma or pressure that may lead to infection or necrosis. The tissues in revisional surgery have already been traumatized and scarred, leading to less-than-optimal blood supply. Any further mishandling will certainly cause problems. Unplanned mishaps during a difficult revision may necessitate postponing additional surgery. At some point, due to fragility of tissue or unforeseen lack of anatomic support, a fully contemplated procedure may not be able to be completed as previously planned. It is better to close at this point and reevaluate further surgery at a later time. Additionally, precarious bleeding that is obscuring the field, or anesthetic complications such as uncontrolled hypertension, coughing, laryngospasm, etc., may necessitate the suspension of operative activity. It is necessary to have optimal conditions to complete a difficult revision. If these conditions cannot be sustained, then the best choice of action is to postpone completion of the procedure until another time.

POSTOPERATIVE C A R E The placement of immediate postoperative dressings should really be considered an extension of the actual surgical procedure, and although it probably does not impact the final result as much as the actual surgical manipulation of tissues, it certainly influences the outcome to quite a considerable degree. The dressings actually help the healing process as a continuation of the surgery. During the

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Mastering Revision Rhinoplasty surgery, the tissues are changed and then placed in certain specific areas. These tissues will begin to heal so that scar tissue or potential scar tissue will eventually mold and blend the tissues together and sometimes contract, which will allow the nose to achieve its final form. Dressings play a very important role in allowing the healing tissues to accomplish this by stabilizing them in a preset way that will enhance healing. It is similar to setting a fractured leg, in that you want the structural elements of the reconstruction to stay where they should be until all the areas have initially healed. Example: One desires upward rotation of the tip and has purposely excised upper lateral cartilage and cephalic border of tip cartilages to set up a healing scar contracture between these two areas to help upwardly rotate the nose. The proper dressing positions these two areas in juxtaposition so that the scar contracture can initate and eventually complete the upward rotation of the nose. Immediate postoperative care centers around bed rest, antihypertensive therapy, which is best begun preoperatively, and controlling undue nausea and coughing. Steroids and antibiotics are given prophylactically to prevent infection and significant edema. It is important to communicate to the patient that a certain amount of edema is preferable and sets up a natural healing process. The edema process washes the area clean and allows for the tissues to begin a healthy healing phase. Intermediate postoperative care centers around the care and maintenance of the dressing. A limited activity level for a period of one to two weeks and a diet high in protein, with vitamins, and low in salt will help ensure a good result. Communication with the patient is essential during this period of time, and any unusual pain, bleeding, fever, purulent discharge, or instability of the dressing should be reported immediately. Long-term care of the patient centers around minimizing direct trauma to the nose and careful observation by the surgeon for a period of up to two years.

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Mastering Revision Rhinoplasty This section serves to present most of the technical information necessary to perform consistently successful revisional and primary rhinoplasty. It is formatted in the general outline following for the sake of clarity and consistency of information presented.

SURGICAL ANATOMY: PERTINENT ANATOMICAL DETAILS Definition of surgical anatomy: In understanding any aspect of surgical manipulation, the first step is obviously to define and understand the intimate relationship of the basic anatomy and comprehend the surgical anatomy, which in a sense is identical but much more complex and ethereal. The surgical anatomy begins only with an outline and understanding of the basic structures and continues with an exquisitely thorough understanding of the interrelationships of these structures and the relative fragility and strength of their tissues. The surgical anatomy of a structure also connotes instantaneous understanding of the three dimensionality of the structure so that at any time in the manipulation of the area, the observant and knowledgeable surgeon will know to within millimeters, and sometimes less, what structures surround, are next to, and deep to the anatomic part being manipulated at any point in time. The surgical anatomy goes beyond pure description to capture the taste and essence of the surgical field. The description of anatomy to surgical anatomy is analogous to describing a steak, but then relating the heat, texture, aroma, and flavor of the meat. To understand the surgical anatomy of such a structure as the nasal valve requires not only understanding of the basic anatomy but also a sense of the feel, taste, and smell of the region. In its ultimate sense, this understanding must transcend the present and extrapolate, at the time of surgery, the future healing processes that will occur and adapt to them at the time of surgery. Thus, not only does the procedure have to take into account the present set of relationships but must also help understand the healing processes in the future to such an extent that judgments and adjustments made at the time of surgery will be obvious and adaptable to the final result in the future. Some areas of the nose do not need such an in-depth understanding to be operated on successfully. The nasal bones, for example, are uniformly strong and certainly remain static in vivo. If they are described and mastered superficially by the surgeon, their manipulation will not be that critical, and will most likely be successful. If, however, the nasal valve is only understood by its basic anatomic components, then disaster awaits the rhinoplastic surgeon.

GLOSSARY Aesthetics: A description of normal or desired aesthetics Aesthetic pathology: Presentation and etiology of presenting problems Technical concepts of reconstruction: Pertinent overview and outline of techniques necessary to effect the repair.

irlttl li THE PRESERVATION AND RESTORATION OF N A S A L F U N C T I O N

THE PRESERVATION OF NASAL FUNCTIONALITY DURING PRIMARY RHINOPLASTY The success of cosmetic rhinoplasty is initially judged by aesthetics; however, the final result is deemed successful only if the internal nose functions as well as the external nose appears. A pinched supra-tip area, for example, that disrupts the natural contours of the nose is usually caused by a combination of overresection of the cephalic borders of the tip cartilages in connection with overresection of the upper lateral cartilages. Although this problem is devastating in terms of nasal aesthetics, it is equally destructive to the nasal functionality by causing significant internal nasal valve destruction. This is just one of many examples of these intimate tissue relationships of which the nasal surgeon must be continually aware. Subdividing a nasal operation into purely functional and aesthetic categories is, at best, artificial, and, at worst, injurious to the patient's health. Every aesthetic change is directly related to nasal function. The famed Bauhaus School fully realized this significance in relation to architectural design over 60 years ago and taught the now famous tenet "form follows function." Surgeons must also appreciate the nose as a living form of architecture and adhere to these worthwhile and fundamental principles. It is only by doing so that we will create both beautifully functioning and aesthetically pleasing noses. The prevention of postrhinoplastic obstruction begins with a careful assessment of the pertinent aesthetic pathology, which is then specifically addressed by a thoughtful, concise, and well-planned operative procedure. It is best to tailor the operation specifically to that patient. Do not try to fit the patient into a model form of rhinoplasty, barely varying the technique from one operation to the next. This can lead to errors in both planning and execution. An example of these mistakes is to routinely perform a full transfixtion incision or to disarticlate the upper lateral cartilages from the septum in a patient in whom no alteration of the dorsum is being considered. The avoidance of nasal obstruction begins in the pre-operative planning steps of the operation. The key tenet at this stage is conservation. If one minimizes the surgical insult to the nose and carefully preserves the anatomic structures while still gracefully and elegantly sculpturing a new form, then the ubiquitous problem of nasal obstruction can be limited. Do only those steps of the rhinoplasty that are necessary to either expose or manipulate the tissues that need re-structuring. Do

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Mastering Revision Rhinoplasty not perform gratuitous steps simply because a textbook has described it as part of the "basic rhinoplasty operation". The most important aspect of pre-operative planning is to determine which areas need altering and which parts can be left alone. This requires mentally molding the undesirable parts of the nose into those that are attractive. This part of the planning process is key and also quite difficult to master. It necessitates employing an operative approach that is quite advanced and totally flexible. Practically this translates into an operative procedure that is eclectic yet direct enough to circumvent the unnecessary steps that cause trauma to the fragile nasal tissues. When planning an operation, I like to conceptualize the nose as a delicate wind tunnel, which delivers to the lungs a stream of smooth, softly flowing air. Obviously this aerodynamic state is altered by scarring, extraneous bits of tissue, or any other structural deformity that will impede the flow of air. If one is conscious of this scenario while performing the rhinoplasty, the results will be rewarding.

Bony Nasal Vault Importance of periosteal envelope.

Dorsal adjustment.

The manipulation of the bony nasal vault during rhinoplasty is essentially limited to removing the upper bony dorsum and narrowing the nasal bones medially. Both of these maneuvers are ideally performed underneath the protection and support of the periosteum. The periosteum actually serves to hold and support the nasal bones after osteotomy and secondarily adds smoothness to the nasal dorsum. Thus it is extremely important that the elevation of the periosteal envelope be exacting and limited. The ideal periosteal elevation should begin approximately 2 mm above the caudal edge of the nasal bones, leaving enough attachment to the upper lateral cartilages so that they will not become detached from the nasal bones and cause obstruction or a dorsal contour deformity. The lateral extent of the elevation should be equal to one-half the distance of the width of the remaining nasal bones after hump removal. This allows the periosteum to bridge the distance between the nasal bones and the maxilla after osteotomy, obviating the obstructive problem of a fully mobile nasal bone collapsing into the pyriform aperture. The upper one-third of the nose is composed of paired nasal bones that articulate with the medial edges of the maxillary bones and the frontal bone. Although these bones coalesce with one another at the nasomaxillary and nasofrontal suture lines, in a practical sense it is best to consider this area as a single bony structure. Because the suture lines do not add any significance to the surgical anatomy, they can be essentially ignored, allowing a more direct and exacting alteration of this area. Anatomically, the bony vault is the sturdiest part of the nose. It is also the most sensitive to change. The key at this very sensitive step is to minimize the assault on the bony vault and to manipulate these tissues delicately and cleanly. The correction of the bony vault begins with dorsal tissue removal. During the planning stage, the amount of bony removal is first estimated and matched to the corresponding segment of the cartilaginous dorsum. To minimize trauma to these

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tissues, a sharp chisel that follows the exact height and pathway of the partially resected cartilaginous dorsum is preferred. The removal begins with the incision of the cartilaginous dorsum with a right angled serrated scissors. The cartilaginous septum and upper lateral cartilages are appropriately resected. An osteotome completes the resection of the nasal bones (Figure 6-1). This technique simplifies the procedure of bony dorsal removal, creates a smooth continuous cut from cartilage to bone, and prevents scarring in the delicate cartilaginous bony junctional area. The upper dorsum is then removed en bloc. Final trimming of the cartilages is reserved for a later step in the rhinoplasty. Lateral osteotomies.

The operative plan at this point should concern the length, height, and width of the nasal bones. Focus on the glabellar area and decide whether narrowing is desirable. Most patients do not need narrowing in this area, so the osteotomies do not have to continue completely to the superior edge of the bones. Inspect the height of the bones and determine if rasping alone can accomplish the desired result. If so, then the internal nose can be spared an operative insult. Because osteotomies are potentially the most damaging part of the rhinoplasty, careful handling of tissue is paramount. Periosteal elevation should be minimized; therefore saws should never be used. My personal preference is to perform the lower portion of the osteotomies with a 3-mm osteotome in such a way as to preserve the delicate periosteal attachments of these bones. The osteotome usually begins its "postage stamp"— -type perforation just above the inferior edge of the bone and continues up until the exact point at which the narrowing of the nose is to be completed. Usually the osteotome ends somewhat short of the glabellar region, with multiple greenstick fracture possibilities determined by the height of this first perforation (Figure 6-lG). It takes no more than three or four perforations to set up the final step, which is the creation of a transverse greenstick fracture by direct digital pressure that exactly matches the height of the last perforation. An equally effective maneuver is to medialize the osteotome while it is still within the perforation of choice, using the osteotome as a fulcrum, thus exerting a tremendous mechanical advantage over the bone and allowing for a more exacting fracture (Figure 6-lH). When the osteotomies are performed in this way, the nose is effectively narrowed, but the important attachments of the periosteum to the base of the nasal bones are maintained, preventing complete nasal bone mobility and displacement into the pyriform aperture (Figure 6-11). Careful insertion of the osteotome into the nose is important in preventing cicatricial scarring of the anterior vestibule. The speculum is placed first into the lateral nasal vestibule and pulled as laterally as possible, acting as a guard. The osteotome is placed through a small stab incision as laterally as possible and then rotated to complete the bony perforations. These maneuvers prevent the internal nasal vestibular incisions from joining each other thus, limiting cicatricial scar formation. Note: medial osteotomies are performed only as required and should only be needed rarely. The postage stamp osteotomy by its very nature does not reach as far superiorly as routine osteotomies, so that fracturing into the substance of the frontal bones is unnecessary.

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Mastering Revision Rhinoplasty

Nasal valve.

Although the nasal valve will be covered in great detail in the context of revisional rhinoplasty, it is important to outline the handling of this very delicate structure during primary rhinoplasty with the hope that proper handling can obviate, or at least substantially minimize, the need for revisions. The nasal valve is that part of the upper lateral cartilage that descends into the superior nasal vault at the juncture with the dorsal septum. The tip cartilage lends considerable, but often overlooked, support to the valve by a bridge of connective tissue and mucosa to the upper lateral cartilage in a suspensory arrangement. This efficient and simplistic structure belies the valve's importance. It is the freely moving and delicate nature of this tissue that allows for the variable increases in nasal resistance so crucial to normal physiologic pulmonary function. The internal nasal valve is the centerpoint of two strategic incisions during routine rhinoplasty: the intercartilaginous incision and the disarticulation of the upper lateral cartilage from the septum. The slightest bit of damage or scarring in this area can cause devastating stenosis; thus it is not surprising that many surgeons advocate complete avoidance of the internal nasal valve during rhinoplasty. When possible, I support this thesis. If the rhinoplasty is limited to minimal change in proportion and size, then I advocate the use of intracartilaginous incisions to access the dorsum and refrain from disarticulating the upper lateral cartilages from the septum. These techniques will allow successful completion of the rhinoplasty and still leave the nasal valve unscarred. When considerable alteration of nasal size and angulation has ensued, it is absurd to expect the nasal valve to automatically adjust itself to the new situation. In effect, the nasal valve now becomes too large for its surroundings and will eventually buckle and sag into the vestibule, causing significant obstruction. Figure 6-2A outlines the concept of upper lateral cartilage trimming, which must be considered any time the planned rhinoplasty dictates significant change in size, angulation, or proportion. When trimming the upper lateral cartilages, adjust the superior aspect to the exact height of the new dorsum. While trimming, the retractor is artificially heightening the cartilage because of its attachment to the soft tissue. During trimming of the caudal aspect, the nasal valve must have adequate mucosa to redrape onto the tip cartilages, so that it can function adequately by moving further into the nasal vestibule as the airway resistance increases. The surgeon should never hinder this important dynamic activity by trimming away too much mucosa from the caudal area of the upper lateral cartilage.

Tip cartilages.

The tip cartilages are the most functionally elegant and aesthetically pleasing structures of the nose. It is imperative that the surgical management of these structures adhere to strict principles of aesthetics and conservatism. Overmanipulation will lead to the dual disasters of deformity and nasal obstruction. Figure 6-2B outlines in general, the extent that the tip cartilages can be altered during rhinoplasty and still stay within the confines of functional safety. The right side of the nose (A) shows the normal tip cartilage. The left side (B, C, D) shows the extent and distribution of tip alteration during primary rhinoplasty. The key

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point here is to never disrupt the continuity of the most caudal aspect of these cartilages, as indicated by arrow D. Within this context, many alterations can safely be performed on the tip. A significant portion of the cephalic borders can be trimmed. The domes can be rotated by excision laterally and morselization medially. Tip grafts can be placed above the intact cartilages to increase projection and definition. In general, as long as the principles of tip support are respected, any alteration of the cartilages is acceptable in a particular circumstance. The potential serious aesthetic and functional consequences following a classic Goldman-tip rhinoplasty attest to the validity of these concepts. If true rotation of the dome is performed with significant lateral trimming of the tip cartilages, then a concomitant amount of internal vestibular skin overlying the resected cartilage should be trimmed appropriately to prevent obstruction in this area. An often ignored component of the tip cartilages are the feet. These present obstructive difficulties when they protrude into the vestibule, so they should be trimmed as described in Figure 6-2D, E. This delicate submucosal dissection of the feet secures an adequate opening into the nostrils. Careful examination of this area is necessary to differentiate this type of obstruction from either a caudal septal deflection or a prominent and skewed nasal spine. These can occur singly or in combination and are corrected quite differently. A very successful and safe alternative to tip cartilage excisional techniques for tip refinement is a modification that I have used successfully for many years. This technique, named the "Incision Only Tip Refinement Technique" can be used in the vast majority of primary and revisional rhinoplasties to refine and thin the tip area. It has the great advantage of obviating the drop off concave deformity associated with tip excisional techniques that occur in some patients (Figures 6-3 and 6-4). Septum.

The spectrum of septal deformities that cause nasal obstruction are legion. It is important to realize that severe septal deformities may not be correctable in a one-stage procedure together with cosmetic rhinoplasty. If the septum can no longer be depended on for internal support after it has been corrected, then the cosmetic rhinoplasty should be performed as a second stage six months later. When feasible, a one-stage procedure is preferred because many of the components of septal surgery impact on the final result of rhinoplasty. For example, it is impossible to straighten the dorsum of a nose when a deviated septum is left intact. It should also be noted that asymptomatic septal deflections can become truly obstructive after a reduction rhinoplasty. A careful inspection of the entire septum is therefore mandatory before performing rhinoplasty, so that all the septal deformities can be identified and corrected. A particularly sensitive area of the septum that causes obstruction because of its location is the upper bony septum composed of the perpendicular plate of the ethmoid. This area has a dual concern during rhinoplasty, because, if deviated, it obstructs a significant amount of air, due to the nature of airflow during inspiration and additionally may not allow inward movement of the nasal bones after osteotomy.

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Rhinoplasty

temperature, physical activity, airborne pathogens and allergens, topical and systemic medications, and food and alcohol ingestion. Since a finite amount of nasal resistance is a functional necessity, an alteration of either too much or too little denies effective airflow to the lungs. Resistance serves two functions. At the local level in the nose it allows for a dispersion of airflow so that the secondary nasal functions can occur efficiently (humidification, warming, and cleansing of the air, as well as dispersion of antibodies to the airstream) and secondarily so that the lungs can effectively allow for an efficient exchange of air across the alveoli.

Internal and External Nasal Port Model Conceptualization of the total nasal unit as a complex kinetic tubular structure with anatomic obstacles throughout the path of the airflow will help simplify the journey of air from the inlet of the nares into the nasopharynx and onward to the lungs. It is helpful to divide the nose into an external port and an internal port. Further clarification of each component into physiologically dynamic and static, as well as those surgically altered, will aid in the description. K = Kinetic S = Static C = Changeable via surgical manipulation Most articles and texts describe nasal anatomy in classical anatomical terms. Few of these writings reconcile the facts of anatomy with physiological reality. It is helpful to think in terms of functional units that transcend anatomic boundaries. Internal port. This consists of the following: internal nasal valve septum turbinates nasal bones External port. This consists of a rim of complex tissues that are comprised of the following: Superficial c o m p o n e n t s Membraneous columella Nasal soft tissue sill Soft tissue and muscle alar rim

Deep components tip cartilages caudal septum premaxilla and crest pyriform aperture

Columella: The columella with its resident feet, legs, and body of the tip cartilages is more an anatomical extension of the nasal tip. It is a functional extension, however, of the caudal septum with respect to the physiology of airflow. Visualizing the above structures as one takes a breath of air, we will follow inspiration and expiration through the nose on the way to the lungs.

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The concept of nasal rigidity is also important when visualizing the nasal unit. The most rigid nasal bones succumb to a semirigid middle nasal vault that leads to a less rigid nasal-tip region.

EXAMINATION OF THE SURGICAL IMPACT ON EACH PART OF THE NASAL PORTS It is worthwhile to examine the potential for surgical damage and/or reconstruction of each anatomic part that comprises the external and the internal port. In this way, one can better balance the degree of surgical intervention so that the final outcome is both satisfactory to the patient aesthetically and functionally.

External Port At the initiation of nasal respiration, there is flaring of the ala that is mediated by the vagus nerve through the facial nerve to the dilator naris and nasalis muscles. The nasal SMAS is an important part of this part of respiration because it ties together in a firm ligamentous sheath all the nasal musculature. Thus, although the SMAS of the nose might seem insignificant in the general context of a nasal reconstruction, it is actually quite important not only for the preservation of this inspiratory reflex but also for maintaining the proper contours over the nose in the postoperative period. Since the nasal alar dilates as the primary function of the nasal muscles at the initiation of the airflow, obviously any alar surgery and surgery that damages the muscle layer will impart an obstructive phenomenon to this area. Since it isn't always possible to preserve all of this muscle layer during rhinoplasty, it is important to preserve some of it. Alar-thinning procedures not only physically limit the size of the external port but also cause subsequent scarring and significant ablation of the SMAS. Damage to the SMAS can also occur during resection or manipulation of the cephalic borders of the lateral-tip cartilages. It is important to note that sometimes it is impossible not to disrupt certain anatomic entities while doing a reconstruction. In this case, one must balance the destructive or obstructive phenomenon with techniques that will allow for an increased airflow through one or both ports. Thus, for example, if an alar-thinning procedure is to be performed and the patient has a widened columella base due to overly large feet of the tip cartilages, then it would d o the patient a service to resect the feet at the same time that the alar-thinning procedure is to be performed. This will act to balance the functional airway during the procedure. The nasal sill is generally not interfered with during rhinoplasty, nor is the soft tissue superior to the sill, so these two areas generally have minimal impact. Drooping nostrils or, more specifically, a reduction in the angle of the tip-columella complex is an important contribution to external nasal-port obstruction. Nasal airflow is immediately improved by upward rotation of the nostrils by directing the stream of air to a more physiologically advantageous high-arched path through the nose. If the angle is too acute, then the nostrils allow the airflow to be directed more inferiorly, which causes more turbulence and obstruction.

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Mastering Revision Rhinoplasty The tip cartilages must be reconstructed so as to maintain support laterally, as discussed more specifically in the tip chapters to follow. The medial portion of the external port includes the membranous columella with its attendant feet and legs of the tip cartilages, as well as the caudal edge of the septum. Thinning, straightening, trimming, and medializing this complex of tissues affords a wonderful opportunity to gain increased airflow.

Internal Port The internal nasal port's most important component is the true internal nasal valve that must, when necessary, be very carefully manipulated. As part of the internal valve, the superior section of the septum is barely several millimeters in width at the juncture with the upper lateral cartilage. Therefore, any deflections or scarring of the septum at this critical point can have significant impact on the airflow. The inferior turbinate represents a dominant force in the improvement of nasal airflow due to its significant size and changing shape. Thus, manipulation of this structure affords an excellent opportunity to gain airflow by either direct subtotal excision or a more conservative outfracture/morselization/injection/cauterization/or cryosurgical radiofrequency ablation. Balancing closing obstructive events with opening non-obstructive events: When considering the flow of air through these two ports, it is essential as one continues through a surgical reconstruction to bear in mind which structures are being changed and how this manipulation will impact the airflow. It is necessary to balance these manipulations with others to keep the airflow constant. Re: a diminution of the height of the nasal dorsum will obviously impact the internal nasal volume. That may mean that a slight spur or deviation in the septum that was asymptomatic at the commencement of the procedure will now take on added physiologic significance and may need to be straightened to afford a final result that does not compromise the airway. Further manipulations may even necessitate a partial turbinectomy to maintain a balanced airflow. Nasal surgery is viable, kinetic, and constantly changing. One must balance the effects of one manipulation with an equally beneficial readjustment of other nasal tissues to ensure an adequately functioning nose.

Obstructing Procedures Damage to dilator nares muscle: 1. Occurs with alar thinning procedures 2. Occurs with manipulation of cephalic-tip cartilages indirectly via partial ablation of the SMAS Partial ablation or destruction of nasal SMAS: 1. Occurs with excision or manipulation of tip cartilages 2. Occurs with improper dissection of dorsal soft tissue envelope

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Drooping of lip-columella complex Damage to external nasal valve Damage to internal nasal valve

Opening Procedures 1. Medializing/straightening/trimming membraneous columella complex, including feet and body of tip cartilages and caudal septum 2. Septal straightening and medializing, including excision of premaxilla and maxiallary crest Figures 6-1 and 6-2 A-C demonstrates a primary rhinoplasty technique that is efficient, artistic, and, above all, one that will preserve nasal functionality. Figure 6-3 and 6-4 demonstrate primary excisional and incisonal-only techniques for tip plasty.

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Figure 6-1.The Preservation of Nasal Functionality During Primary Rhinoplasty

Figure 6-1 A. Dorsal height adjustment. Dorsal reconstruction begins with a line-of-sight estinnate of the annount of cartilaginous and bony adjustnnents necessary to obtain the correct dorsal height. Dorsal adjustment and removal of cartilaginous-tissue components (dorsal septum and dorsal upper lateral cartilages) and followed by adjustment of the nasal bones. Figure 6-1B. Cartilaginous dorsal height adjustment. Cartilaginous-tissue height adjustment is begun by sharply incising the junction of the upper lateral cartilage to the septum. If this step and the subsequent trimming of the upper lateral cartilages as depicted in Figure 6-1C and 6-2A are performed cleanly and neatly then there is only minimal trauma to the nasal valve. Of course, this step is performed only if the dorsal height needs adjustment. Figure 6-1C. Adjustment of upper lateral cartilage. The exact height of the upper lateral cartilage is estimated from the line-of-sight measurement taken in Figure 6-1 A.The upper lateral cartilage is then appropriately trimmed and the tissue removed. Figure 6-ID. Adjustment of dorsal septal cartilage. The height of the dorsal septal cartilage is adjusted with a serrated, sharp scissors, stopping just short of the bony nasal dorsum. Figure 6-1E. Bony dorsal height adjustment. A sharp chisel is then inserted into the same plane of dissection previously made in the septum and follows the exact height and pathway already outlined by the scissors.The chisel follows the cut through the last portion of cartilaginous dorsum into the bony nasal dorsum as one continuous incision. Figure 6-1F. Unroofed nasal pyramid. The roof of the nose is now open in preparation for the osteotomies to follow. Figure 6-1G. Postage-stamp osteotomies. Postage-stamp osteotomies secure the continuity of the periosteum from the face of the maxilla onto the nasal bones. An added advantage to this type of osteotomy is minimal trauma and the assurance of a greenstick fracture superiorly which adds to the support of the nasal bones. Minimal narrowing in the glabellar region is usually desirable, but if true glabellar narrowing is deemed necessary then the last postage-stamp chisel cut is adjusted more superiorly Figure 6-1H. Mechanical-advantage osteotomy. Instead of purely digital pressure to secure the osteotomy a more mechanically advantageous method is to utilize the osteotome as a wedge, medializing and in-fracturing the nasal bone as the osteotome is moved laterally to medially Figure 6-1 i. Periosteal support of nasal bones. The right side of the nose illustrates the nasal bone supported by an intact periosteum. It is mobile enough to accomplish narrowing but will not be displaced into the nasal interiorThe left side demonstrates a hypermobile nasal bone with displacementThis situation is to be avoided at all costs, because the deformity associated with this bone displacement is very difficult to correct.

Technique

6-lA

6-lB

6-lD

6-lE

6-lF

6-lG

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Figure 6-2A-6-2C.The Preservation of Nasal Functionality During Primary Rhinoplasty; 6-2D-6-2E. Reconstruction of Foot-of-Tip Cartilage; 6-2F-6-2H. Nasal Port Models

Figure 6-2A. Upper lateral cartilage trimming. Arrow A shows trimming of the medial aspect of the upper lateral cartilage. Arrow B shows trimming of the caudal aspect. Both cuts must be extremely accurate to avoid obstructive problems. From a cosmetic standpoint, cut B will aid in readjusting the nasolabial angle, whereas cut A is necessary to ensure a smooth supra-tip region and to prevent the formation of a" polly beak" deformity Figure 6-2B.Tip cartilage excisonal guidelines. The normal-tip cartilage is depicted in (A). Area (C) reflects the total amount of resection of the tip cartilages, leaving the amount of cartilage corresponding to (B).This area approximates the size and extent of tip cartilages seen in refined tips.The key support area of the nasal tip is outlined in (D). Violation of this area will lead to collapse. Figure 6-2C. Mucosal trimming. It is imperative to trim the mucosa overlying the cartilaginous surfaces. This will allow excellent healing and approximation of tissues with minimal scar formation. All mucosal surfaces surrounding the septum, including dorsally and caudally along the columella, should be cut back so that at least I mm of cartilage extends beyond the mucosal surface. It is particularly helpful along the dorsal aspect of the septum to obviate the additional soft tissue that may contribute to a"polybeak" deformity Caudal septal mucosal trimming aids in a well-formed and smooth line of closure, which is aesthetically pleasing and allows the membraneous columella to maintain a uniform contour Figure 6-2D. Nasal obstruction secondary to large or deflected foot-of-tip cartilage. The right nostril is obstructed secondary to a large deflected foot of the tip cartilage. Figure 6-2E.Trimming of foot-of-tip cartilage. Trimming of the foot-of-the-tip cartilage when it is either too large or deflected into the nasal vestibule is a simple, direct solution to this problem.The obstructing cartilage is removed after submucoperichondrial dissection of the offending footThis dissection is surprisingly difficult due to the thinness of the tissue overlying the foot. Care must be taken not to cut through or damage the soft tissue envelope when undermining. Figure 6-2F. Internal nasal port model. The arrow follows the airflow through the internal nasal port.The components of this port are the internal nasal valve, septum, turbinates, and nasal bones. Figure 6-2G. External nasal port model (superficial components). The superficial components include the membranous columella, nasal soft tissue sill, and the soft tissue and alar rim with the muscular attachments. Figure 6-2H. external nasal port model (deep components). The components of the external nasal port, deep to the superficial components, are the tip cartilages, the caudal septum, including the premaxilla, and the bony pyriform aperture.

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6-2A

6-2C

6-2D

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Figure 6-3.The Preservation of Nasal Functionality '^Incision-Only Tip-Refinement Technique"—Basic Technique The "incision-only tip refinennent technique" allows for tip refinennent in most circunnstances, while still nnaintaining the architectural integrity of the tip cartilages.This is acconnplished by refining the tip, but still allowing tip cartilages to bridge the gap between the tip and the rest of the nose.This technique is very predictable in allowing for a symnnetrical refinement of the tip area, yet still maintaining a functional and elegant-appearing tip. It is a simple technique to learn and also allows one the opportunity to switch to a more normal resection of the tip cartilages if this is necessary during the course of the surgery Tip morselization techniques can also be added if deemed appropriate and necessary Figure 6-3A. Routine excisional techniques for tip refinement. Upper. Frontal view showing large tip cartilages to be refined. Lower: Frontal view showing routine excisional techniques for tip refinement. Some advocate the more conservative excision as outlined on the right side of the nose (A). Other times a full transverse excision is performed, as outlined on the left side of the nose (B). Figure 6-3B. Excisional techniques for tip refinement. Upper: Lateral view of excisional technique corresponding to A in Figure 6-3A Lower: Lateral view of excisional technique corresponding to B in Figure 6-3A. Figure 6-3C. Convex tip deformity secondary to excisional techniques. Lateral view of nasal-tip area that shows the supra-tip, concave-tip deformity that commonly occurs after routine excisional tip-refinement techniques.This generally occurs late in the healing process and worsens with time. Figure 6-3D. Incision-only tip-refinement technique—basic technique. The basic incision is made into and through the tip cartilage corresponding approximately to the line of dissection illustrated in Figure 6-3A/ Lower/Arrow B. Figure 6-3E. Incision-only tip-refinement technique—explanation of effect. The incision only technique works in part because of the influence of the ligamentous structures on the tip cartilages.There are two sets of ligaments that are dominant in their attachments to the tip cartilages.The first set attaches laterally to the edge of the tip cartilage and pulls laterally into the pyriform aperture.The second set attaches to the undersurface of the medial part of the tip cartilage on the cephalic edge and inserts into the upper lateral cartilages.These ligaments exert their pull downward into the nose and superiorly It is just these forces exerted on the tip cartilages by the ligaments that allows the incision only technique to work Figure 6-3F. Incision-only tip-refinement technique—explanation of effect. The lateral view better illustrates the attachments of the second set of ligaments and explains why the cephalic portion of the tip cartilage moves in a direction deep to the original plane of the tip cartilages. Figure 6-3G. Incision-only tip-refinement technique—lateral ligament pull. This view illustrates the lateral ligament's insertion mostly into the cephalic edge of the tip cartilage.This allows for a lateral pull of this portion of the cartilage after it is cut away from the main body of the tip cartilage. Figure 6-3H. Incision-only tip-refinement technique—basic technique. This view illustrates the combined movement of the cephalic portion of the tip cartilage due to the combined forces exerted by the ligaments.The end effect is to move the cut portion of the tip cartilage in a direction inward towards the interior of the nose, while also moving cephalically and somewhat laterally These diverse forces allow for the definition of the tip without excising tip cartilage.This maintains the architectural integrity of this portion of the tip while still allowing for tip definition.

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Figure 6-4.The Preservation of Nasal Functionality Incision-OnlyTip-RefinementTechnique Advanced Technique

Figure 6-4A. Incision-only tip-refinement technique—advanced technique (incremental definition). The advanced technique causes the cephalic portion of the tip to separate itself incrennentally fronn the caudal portion of the tip cartilage by loosening the soft tissue envelope surrounding the tip cartilage.The first degree of separation in the advanced technique begins with the incision through the cartilage. Figure 6-4B. Incision-only tip-refinement technique—advanced technique (incremental definition). The cephalic portion is allowed to separate by undermining the vestibular skin fronn the cephalic part of the tip cartilage. Figure 6-4C. Incision-only tip-refinement technique—advanced technique (incremental definition). This allows for even nnore definition in the tip region. Figure 6-4D. Incision-only tip-refinement technique—advanced technique (increased definition). If even more definition is desirable, the superficial soft tissue and skin envelope is undermined in addition to the vestibular skin. Figure 6-4E. Incision-only tip-refinement technique—advanced technique (increased definition). The lateral view shows that the cephalic part of the tip cartilage is pulled even more superiolaterally and deeper into the nose because of the increased release of the soft-tissue envelope. This technique therefore, allows an exquisite amount of control over the amount of definition desired in the tip region. Figure 6-4F. Incision-only tip-refinement technique—^advanced technique (maximum definition). Maximum definition using this technique is accomplished with the aid of morselization of the lateral edge of the cephalic part of the tip cartilage.The technique is begun by incising the cartilage and undermining the entire soft-tissue envelope skin surrounding the cephalic area of the tip cartilage, as shown in Figure 6-4D-E. Figure 6-4G. Incision-only tip-refinement technique—advanced technique (maximum definition). After exposure, the tip of a fine hemostat is used to morselize the lateral edge of the tip cartilage. Figure 6-4H. Incision-only tip-refinement technique—advanced technique (maximum definition). Maximum definition is attained by thinning the cephalic part of the tip cartilage while totally undermining the soft-tissue envelope, thus allowing maximal movement of the cephalic part of the tip cartilage in a superio-lateral and inward direction.

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Figure 6-5. Primary Rhinoplasty with Preservation of Nasal Functionality

Figure 6-5A. Pre-op lateral view of primary rhinoplasty with dorsal cartilaginous and bony removal, with full preservation of nasal functionality. This patient is shown with a dorsal cartilaginous and bony hunnp. Figure 6-5B. Post-op lateral view of primary rhinoplasty with dorsal cartilaginous and bony removal, with full preservation of nasal functionality. Postoperatively this patient exhibits a snnooth profile without evidence of previous dorsal hump.The preservation technique ensures an aesthetically pleasing result without nasal obstruction. Figure 6-5C. Pre-op lateral view of primary rhinoplasty with dorsal hump removal and upper lateral cartilage trimming, with full preservation of nasal functionality. This patient exhibits a cartilaginous and bony hunnp associated with redundant upper lateral cartilages. Figure 6-5D. Post-op lateral view of primary rhinoplasty with dorsal hump removal and upper lateral cartilage trimming, with full preservation of nasal functionality. Postoperatively this patient exhibits a strong feminine profile that blends into the tip area, very naturally due to the trinnming of the transition zone of upper lateral cartilages. Figure 6-5E. Pre-op lateral view of primary rhinoplasty with heightened nasal bony dorsum. This patient exhibits a heightened bony nasal dorsunn. Figure 6-5F. Post-op lateral view of primary rhinoplasty with decrease in height of nasal bony dorsum.. Post-operatively this patient exhibits a lower bony nasal dorsunn using techniques as shown in figure 6-1D-E.

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Figure 6-6. Primary Rhinoplasty with Preservation of Nasal Functionality

Figure 6-6A. Pre-op frontal view of primary minimal-tip rhinoplasty. This patient exhibits a disproportionate tip due to minimally enlarged tip cartilages. Figure 6-6B. Post-op frontal view of primary minimal-tip rhinoplasty. Postoperatively this patient exhibits a more refined and proportionate tip.This was achieved by excising a proportionate amount of tip cartilages, as seen in Figure 6-2B, thus leaving an approximate amount of tip cartilages equal to the distance midway between B and C, as in Figure 6-2B. Figure 6-6C. Pre-op frontal view of primary moderate-tip rhinoplasty. This patient exhibits a disproportionate tip due to moderately enlarged tip cartilages. Figure 6-6D. Post-op frontal view of primary moderate-tip rhinoplasty. Postoperatively this patient exhibits a more refined and proportionate tip.This was achieved by excising a proportionate amount of tip cartilages, as seen in Figure 6-2B,thus leaving an approximate amount of tip cartilages corresponding to the area in B. Figure 6-6E. Pre-op frontal view of primary maximal-tip rhinoplasty. This patient exhibits a disproportionate tip due to maximally enlarged tip cartilages. Figure 6-6F. Post-op frontal view of primary maximal-tip rhinoplasty. Postoperatively this patient exhibits a more refined and proportionate tip.This was achieved by excising the maximal amount of tip cartilages, yet still protecting the structural and functional integrity of the nose.This patient was left with the amount of tip cartilages corresponding to area D in Figure 6-2B.

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Figures 6-7A-D. Primary Rhinoplasty Results Without Adequate Mucosal Trimming; 6-7 E-R Primary Rhinoplasty with Resection of Feet of Tip Cartilages For Preservation of Nasal Functionality

Figure 6-7A. Pre-op frontal view of primary rhinoplasty. This patient exhibits excess tissue causing significant overprojection. Figure 6-7B. Post-op frontal view of primary rhinoplasty with reduction of projection but significant deformity secondary to inadequate mucosal trimming. Postoperatively this patient exhibits a significant soft tissue nnass in the tip and supra-tip region that was in part due to inadequate mucosal trinnnning. Correct technique that could have prevented most of this deformity is shown in Figure 6-2C. Figure 6-7C. Pre-op lateral view of primary rhinoplasty. In the lateral view the overprojection of the lower half of the nose is evident Figure 6-7D. Post-op lateral view of primary rhinoplasty with reduction of projection but significant deformity secondary to inadequate mucosal trimming. The classic "polly beak" deformity is demonstrated due to inadequate mucosal trimming. Figure 6-7E. Pre-op frontal view of primary rhinoplasty with vestibular obstruction secondary to prominent feet of tip cartilages. This patient exhibits prominent tip cartilage feetThe left is more obstructive than the right. Figure 6-7F. Post-op frontal view of primary rhinoplasty after prominent-tip cartilage feet were trimmed. Postoperatively this patient has no obstructive phenomenon due to excess-tip cartilage feet because they were appropriately excised following the technique shown in Figure 6-2E.

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Figure 6-8. Concave-Tip Deformity Secondary to Excisional Techniques

Figure 6-8A. Pre-op lateral view of primary-tip rhinoplasty with routine excisional technique. This patient exhibits excessive bulk in the tip cartilages. Figure 6-8B. Post-op lateral view of primary-tip rhinoplasty showing convave-tip deformity This patient had a routine excisional-tip technique as shown in Figure 6-3A, incision B. The patient now exhibits significant tip reduction but a noticeable concave-tip deformity. Figure 6-8C. Pre-op 3/4 view of primary-tip rhinoplasty with routine excisional technique. This patient exhibits excessive bulk in the tip cartilages. Figure 6-8D. Post-op 3/4 view of primary-tip rhinoplasty showing concave-tip deformity. This patient had a routine excisional-tip technique following incisions as shown in Figure 6-3A, incision A.The patient now exhibits significant tip reduction but a noticeable concave-tip deformity. Figure 6-8E. Pre-op 3/4 view of primary-tip rhinoplasty with routine excisional technique. This patient exhibits excessive bulk in the tip cartilages. Figure 6-8F. Post-op 3/4 view of primary-tip rhinoplasty showing concave-tip deformity. This patient had a routine excisional-tip technique following incisions, as shown in Figure 6-3A, incision B.The patient now exhibits significant tip reduction but a noticeable concave-tip deformity and an external nasal valve collapse.

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Figure 6-9. Incision-Only Tip-Refinement Technique

Figure 6-9A. Pre-op frontal view of incision-only tip-refinement technique— basic technique. This patient exhibits excessive bulk in the tip cartilages. Figure 6-9B. Post-op frontal view of incision-only tip-refinement technique— basic technique. This patient had the incision-only tip-refinement technique—basic technique and exhibits a significant reduction in tip volume.This technique, however; maintains the structural integrity and thus the natural contour of the tip and supra-tip region. Figure 6-9C. Pre-op frontal view of incision-only tip-refinement technique— advanced technique (incremental definition). This patient exhibits excessive bulk in the tip cartilages. She has slightly more tip to nose disproportionality and thus needs the more advanced incision-only technique to give the nasal tip more definition. Figure 6-9D, Post-op frontal view of incision-only tip-refinement technique— advanced technique (incremental definition). This patient had the incision-only tip-refinement technique—advanced technique, in which the vestibular skin was undermined, as shown in Figure 6-4A,B,C. Figure 6-9E. Pre-op 3/4 view of incision-only tip-refinement techniqi advanced technique (incremental definition). Same patient as above. Figure 6-9F. Post-op 3/4 view of incision-only tip-refinement technique advanced technique (incremental definition). Same patient as above.

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Figure 6-10. Incision-Only Tip-Refinement TechniqueAdvanced Technique

Figure 6-1OA. Pre-op 3/4 view of incision-only tip-refinement technique— advanced technique (increased definition). This patient exhibits excessive bulk in the tip cartilages but needs even nnore definition than the previous patient to nnake the tip of the nose proportionately refined with the rest of the face and nose. Figure 6-1 OB. Post-op 3/4 view of incision-only tip-refinement technique— advanced technique (increased definition). This patient had the incision-only tip-refinennent technique—advanced technique (increased definition). In this technique the entire superficial tissue and skin envelope is undernnined in addition to the vestibular skin, as shown in Figure 6-4D.This allows for a nnaximal pull of the cephalic portion of the tip cartilages by the ligannentous structures in a superio-lateral vector; as shown in Figure 6-4E. Figure 6-1OC. Pre-op frontal view of incision-only tip-refinement technique— advanced technique (maximum definition). This patient exhibits excessive bulk in the tip cartilages. She needs the nnaxinnal amount of tip definition that is possible with this technique. Figure 6-1OD. Post-op frontal view of incision-only tip-refinement technique— advanced technique (maximum definition). This patient had the incision-only tip-refinement technique—advanced technique, in which the entire soft tissue and vestibular skin envelope was released and the lateral portions of the cephalic borders of the tip cartilages were morselized, as shown in Figure 6-4F-G. Figure 6-1OE. Pre-op base view of incision-only tip-refinement technique— advanced technique (maximum definition). Same patient as above. Figure 6-1 OF. Post-op base view of incision-only tip-refinement technique— advanced technique (maximum definition). Note the significant reduction in tip volume but the exquisitely natural shape of the tip.The external valves are also completely intact, with no loss of structural integrity This is due to the ability of this technique to add definition and contour but maintain anatomic structure.

Figure 6-1OA

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•1 BONY NASAL VAULT

SURGICAL ANATOMY The bony nasal vault is composed of the two nasal bones, attached to the frontal bone superiorly and laterally to the maxillary bones. There is a curving transition with the frontal bones, and inferiorly the nasal bones overlie and protect the insertion of the upper lateral cartilages, which attach to their undersurface. Although the nasal bones are a paired structure attached to each other and to two other bones superiorly and laterally, it is advantageous in most revisional circumstances to consider the bones as a single bony complex. In some cases, however, it will be necessary to split them apart and move them medially or laterally as separate entities. The nasal bones act as one of the main support mechanisms for the nose. Some reconstructive efforts will utilize the nasal bones to virtually hold up the entire nose. Although there is some support at the lower end of the nose from the columella tip complex, the strongest and most reliable support is derived from the nasal bones and their bony attachments to the rest of the face.

AESTHETICS The bony nasal vault defines the relationship of the forehead to the nose and influences the characteristics of the nose related to slope and angulation. It can create either a strong masculine root or a soft gently curving feminine line with the rest of the face and the lower two-thirds of the nose. In both sexes the nose should have a high, strong defining point as it curves slightly downward from the forehead. Male and female aesthetics differ in many aspects and particularly in relationship with the slope and angulation of the bony nasal vault as it articulates with the forehead. Males and females both should have a high, well-defined nasal root, which adds strength and beauty to the nose; however, the male nose is invariably higher than the female's. This height gives definition to the entire face and helps to separate the eyes. Ethnic considerations aside, even Asian revisional surgery usually requires augmentation to this area. The importance of a strong, high nasal root is thus essential in almost all noses to help define the nose. The curvature of the root of the nose should flow in a gentle curve from the forehead. It should not come directly off the forehead in a straight manner, or it will give a harsh, unnatural, somewhat Neanderthal look to the rest of the nose.

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AESTHETIC

PATHOLOGY Revisions related to the upper bony dorsum revolve around two central themes: projection as viewed from the lateral perspective and alignment/position as viewed from the frontal perspective. Subthemes include convex and contour deformities that overlie the nasal bones proper, or present in the transition zone between the nasal bones and the upper lateral cartilages, or between the nasal bones and the forehead region.

PROJECTION Many revisional problems fall into the category of too much or too little projection. Taking off too much bony dorsum is a common reason for revisional surgery, and requires the addition of material to augment this area. Often times not only is too much bony dorsum removed during primary rhinoplasty but also cartilaginous dorsal tissue is removed. An ideal reconstructive model for this type of problem is the structure and composition of an appropriately removed dorsal hump. If only bony tissue is deemed necessary to reconstruct, careful measures must be taken to override the cartilaginous dorsum slightly so that the transition zone of the reconstruction will have a smooth contour.

ALIGNMENT The bony nasal vault defines the line of the nose in a frontal view, and any twist or curvature in this area will be readily apparent. This shift, however, is made worse by the anatomical fact that the upper lateral cartilages are anchored to the undersurface of the nasal bones and will follow the aberrant curves of these bones. Thus, proper nasal bone alignment is essential because of this anatomic entity. Due to the intrinsic anatomy, a deformity of malaligned nasal bone causes the upper lateral cartilage to be carried "along for the ride," compounding the deformity.

POSITION Positional effects of the bony nasal vault relate to nasal bones that are properly aligned but are either too wide or too narrow in comparison to the rest of the nose. This incorrect proportion gives the lateral contour of the nose a discontinuous appearance (nasal discontinuity). Nasal bones that look too wide serve as a red flag to highlight an underlying problem that did not allow for their proper medialization. It is a mistake to assume that the primary surgeon did not perform the osteotomies correctly. Instead, the revisional surgeon should inspect the area between the nasal bones for causes of nonmedialization. Failure of the nasal bones to medialize is most often due to abundant cartilaginous or bony tissue separating the nasal bones in the area of the dorsal septum, just underlying the nasal bones. If this area is not either curetted or chiseled out, or in the case of a purely cartilaginous problem, morselized, then the nasal bones cannot medialize, causing bony nasal vault to

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middle nasal vault discontinuity. Sometimes the septum directly beneath the nasal bones must be partially removed to effect the medialization. Incomplete osteotomies between the frontal and nasal bones, sometimes due to very strong intersuture articulation, will also result in failure to medialize. Additional osteotomies placed superiorly will be necessary to free this area. Usually attachment to the maxillary bones is not a major cause of failure to medialize but can be significant in certain cases. Full medial and lateral osteotomies are sometimes necessary to free up the nasal bones.

CONTOUR DEFORMITIES Contour revisional problems can be categorized into convex or concave deformities that can exist as separate entities or in combination with problems of projection, alignment, or position. The contour deformities are caused by disruption of bony tissue, either from previous trauma that was not properly attended to during a primary rhinoplasty or caused iatrogenically during the rhinoplasty. Convex deformities result from (1) neoosteogenesis, (2) scar tissue formation, or (3) overriding of nasal bones. These problems can most often be expeditiously handled by localizing the problem and sharply rasping the excess tissue away. Concave deformities, which are in general much more difficult to repair, result from inefficient or unequal osteotomies, causing a separation of the nasal bones or a collapse into the nasal vault, either unilaterally or bilaterally.

TECHNICAL CONCEPTS OF RECONSTRUCTION The ability to mobilize and shape the nasal bones to the desired contour is essential. The first step is to properly align the nasal bones in a straight fashion and then set the proper height and angle of slope. Next, the important forehead nasal angle is determined and executed. The contour deformities that still exist can now be considered for repair. The philosophy of reconstruction is to set the framework of the nose plumb and square before you correct contour deformities. Many of the revisional problems of the bony nasal vault are caused by hypermobility of the nasal bones during primary rhinoplasty. This is caused during osteotomies when the nasal bones are disarticulated from their periosteal attachments, and then in the postoperative healing phase when the nasal bones are able to move aberrantly. Thus the less mobile the nasal bones the better the reconstructive effort will be. One should mobilize the bones just enough to allow their movement to the desired place, and, if not necessary, do not even complete the osteotomies. In revisional surgery there is often significant scarring of the periosteum, which can be used to advantage during the reconstruction. Treating this periosteum with respect and performing perforating osteotomies, or only digital pressure bone movement or simply rasping the nasal bones without osteotomies, will obviate the dreaded complication of having a nasal bone collapse into the nasal vault and will greatly facilitate healing and eventual stability in the postoperative phase.

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Mastering Revision Rhinoplasty Nasal bone collapse that presents in a revisional setting is usually an old collapse in which there has been enough time for the scar tissue surrounding the periosteum to form and stabilize the bone. The nasal bone may be concave; however, it will act as a stabilized platform for rebuilding. A newly collapsed bone should be uplifted as much as possible even to the extent of overcorrection, and then as soon as the remainder of the surgery is completed, significant packing is placed under the bone to stabilize it for at least one week. Minimal trauma to the periosteum and the utilization of postagestamp-type osteotomies will obviate the need for this correction. The most common cause of nasal bone collapse, either partial or full, is overmobilization of the nasal bones and disruption of the periosteum. After osteotomy, periosteal attachments are necessary to ensure bone stability and placement. Rhinoplastic principles that promote overmobilization of the bony nasal vault should be avoided.

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Figures 7-1A-7-1E. Reconstruction of Bony Nasal Vault Overprojection; 7-1F-H. Reconstruction of Bony Nasal Vault Uuderprojection (Minimal)

Figure 7-1 A. Overprojection of nasal dorsum (bony and cartilaginous). Overprojection can occur anywhere along the bony nasal vault. It is usually not isolated to the bony complex but extends into the cartilaginous connponents of the middle nasal vault. Correction of this overprojection begins by identifying a line of resection that takes into account the excess overprojection in the middle nasal vault as well, and also anticipates the line of bony removal that will define the nasofrontal angle. Figure 7-1B. Overprojection of nasal dorsum (cartilaginous). The excess tissue in the middle nasal vault is excised first.This includes dorsal cartilaginous septum and bilateral upper lateral cartilages. Figure 7-1C. Overprojection of nasal dorsum (bony chisel resection). Once the new profile line is established by the cartilaginous incision, the chisel is used to complete the dissection into the bony nasal vault. Figure 7-1D. Overprojection of nasal dorsum (bony rasp). The superficial layer of the bone is rasped to smooth the contour Fine tuning of the nasofrontal angle is performed with the appropriate curved rasp, after osteotomies. If overprojection occurs isolated to just the area in the nasofrontal angle, then chisel and rasp are used alone to redefine the angle. Figure 7-1E. Corrected result. Nasal profile is now in proportion after overprojected bone and cartilage are resected. Figure 7-1F. Underprojection of bony nasal dorsum (minimal). Correction of slight-to-moderate bony nasal vault underprojection is best done by "borrowing" bony tissue from the maxillary bone and using this unit as a single bony componentThis intact bony tissue is then medialized, and like a triangular tent in which the sides are medialized,the height of the tent will increase.The amount of increase is directly proportional to the amount of medialization that can occur and still give a pleasing line to the width of the nose. Figure 7-1G. Maxillary Bone Osteotomy. The osteotomy will be below the nasal bone maxillary bone suture line and will be on the same plane as the maxilla, as low as possible. Figure 7-1H. Frontal view of maxillary bone borrowing. Upper diagram shows pre-op frontal view of nose. Lower diagram shows bone borrowed from the maxilla and carried medially as one unit after the osteotomy has been performed.This effectively heightens the underprojected nose. When performed bilaterally the tent gets higher and narrower; Re: height of B is greater than A. Width of B' is less than A'.

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Figure 7-2A-7-2C. Reconstruction of Bony Nasal Vault Underprojection (Moderate to Severe); 7-2D-R Reconstruction of Bony Nasal Vault Alignment Deformities; 7-2G-I. Reconstruction of Bony Nasal Vault Positional Deformities Moderate to severe underprojection is corrected with an autogenous cartilage sandwich graft that is fashioned to duplicate the shape and contour of the hump, which had been rennoved during the prinnary rhinoplasty, only nnore proportionate to the remainder of the nasal tissues. Many alternatives for fashioning this hump are available. Figure 7-2A. Building of dorsal autogenous cartilage sandwich graft. Sheets of autogenous cartilage are glued together and carved into the appropriate shape. Figure 7-2B. Placement of sandwich graft. Through an intercartilaginous incision, the preformed graft is placed over the bony nasal vault defect The graft is tailored and beveled to contour to the inferior and superior transition zones. After the graft is fitted into position, adhesive is placed on the deep and superficial surface of the graft to aid in permanent positioning. Figure 7-2C. Contour refinement of bony dorsum. If the contour of the nose needs refinement either superficial to the graft or at the inferior or superior edges of the graft, then "tissue clay" injected around the graft in these areas is a great aid in contour refinement. A syringe is placed through the same intercartilaginous incision and the appropriate amount of "tissue clay" is injected.The incision is closed appropriately and the nose is dressed. Figure 7-2D. Bony nasal vault malalignment. Malalignment of the nasal bones is compounded by the fact that the upper lateral cartilage is anchored to its undersurface and will be additionally misguided. Figure 7-2E. Osteotomy realignment of bony nasal vault. Proper realignment of the bony nasal vault is performed by a combination of medial/lateral/and or superior osteotomies with appropriately sized chisels. Figure 7-2F. Corrected result. As the bony nasal vault is realigned, the upper lateral cartilages straighten out resulting in a complete realignment Figure 7-2G. Bony nasal vault deformity secondary to widened nasal bones. Nasal bones present as being too wide compared to the remainder of the nose; Re: bony nasal vauft to middle nasal vault discontinuity The upper lateral cartilages are still attached in a secure fashion to the nasal bones.There has tieen no trauma or disarticulation between the nasal bones and the upper lateral cartilages. Figure 7-2H. Reconstruction with osteotomies. Proper osteotomies laterally will usually effect the correction. Additional superior osteotomies are sometimes needed to properly medialize the nasal bones.This will be effective only when internal nasal exam reveals the septum to be straight and the area between the nasal bones clear of tissue or debris. Figure 7-21. Corrected result. Normally positioned nasal bones, proportional to the rest of the nose.

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Figure 7-3. Reconstruction of Widened Bony Nasal Vault (Failure of Nasal Bones to Medialize) Failure of nasal bones to nnedialize is due to an obstructive phenonnenon between the two nasal bones.This can be due to either one or a connbination of (I) thickened or deviated nasal septum, (2) bony or cartilaginous tissue formed between the nasal bones (usually as a result of previous trauma to this area). Figure 7-3A. Failure of nasal bones to medialize secondary to thickened septum. Nasal bones are widened due to a thickened septal cartilage not allowing the nasal bones to medialize during previous osteotomies. Figure 7-3B. Morselization of thickened septum. Thickened septum is morselized to allow room for the nasal bones to medialize. Figure 7-3C. Corrected Result. After appropriate osteotomies, the nasal bones can now medialize into a normal position. Figure 7-3D. Failure of nasal bones to medialize secondary to severely deviated septum under nasal bones. Nasal bones are widened due to a severely deviated nasal septum not allowing the nasal bones to medialize during previous osteotomies. Figure 7-3E. Removal of deviated septum. Deviated portions of nasal septum are removed with biting forceps. Figure 7-3F. Corrected result. After appropriate osteotomies, the nasal bones can now medialize into a normal position. Figure 7-3G. Failure of nasal bones to medialize secondary to bony tissue at root of nose. Nasal bones are widened due to bony tissue at root of nose. Figure 7-3H. Removal of extraneous bony tissue at root of nose. Extraneous bony tissue obstructing nasal bone medialization is removed enbloc with chisel or curetted away with a rongeur Figure 7-31. Corrected result. After osteotomies, the nasal bones can now medialize into a normal position.

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Figure 7-4. Reconstruction of Contour Deformities

Figure 7-4A. Presentation of concave deformities. Concave deformities present as step-off depressions within the nasal bones secondary to traunnaThey also present as depressions anywhere over the nasal bone area. Figure 7-4B. Augmentation of concave deformities. Augmentation of these slight deformities is best performed with a bone substitute material. Figure 7-4C. Corrected result. Augmentation is complete, and the contours overlying the nasal bones are smooth. Figure 7-4D. Partial unilateral nasal bone collapse. Partial collapse of the right nasal bone with its attendant concavity is presented. Figure 7-4E. Cartilaginous graft. Autogenous cartilage graft shaped in this way will expeditiously correct this problem. Stippled areas represent areas of morselization to slightly flatten out peripheral edges to minimize lateral step-off deformities from the graft to the adjacent nasal tissues. Figure 7-4F. Corrected result. Right-sided collapse is corrected. Figure 7-4G. Convex deformities. Convex deformities can occur anywhere in the bony nasal vault region.They are most common, however inferiorly Figure 7-4H. Rasp reconstruction of convex deformities. Rasping affords the best approach to these problems. If the convexity is quite large, then chisel excision of the offending bone followed by rasp is preferable. Figure 7-41. Corrected result. Normal-appearing nasal dorsum.

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Figures 7-5 A - B . Reconstruction of Bony Nasal Vault Overprojection; 7-5C-D. Reconstruction of Bony Nasal Vault Underprojection (Minimal); 7-5E-F. Reconstruction of Severe Bony Nasal Vault Underprojection

Figure 7-5A. Pre-op lateral view of reconstruction of bony nasal vault overprojection. This patient exhibits a dorsal cartilaginous and bony hunnp. Figure 7-5B. Post-op lateral view of reconstructed bony nasal vault overprojection. This patient underwent the procedures as outlined in Figure 7-1B-D. Postoperatively, this patient exhibits a snnooth profile without evidence of previous dorsal cartilaginous and bony hump.The sequential rennoval of cartilage and bone ensures an aesthetically pleasing profile with a smooth continuity between the bony and cartilaginous components. Figure 7-5C. Pre-op frontal view of patient exhibiting a widened and minimal underprojection of the bony nasal dorsum. This patient exhibited a combined deformity consisting of a widened bony nasal dorsum that is minimally underprojected. Figure 7-5D. Reconstructed result corrected by medializing the bony nasal vault and borrowing maxillary bone. Postoperatively this patient exhibits a stronger; thinner; and higher profile.The judicious borrowing of maxillary bone, as shown in Figure 7-2 G-H, allowed for the dual result of thinning and heightening the bony nasal vault As discussed above, the intimate anatomy of the upper lateral cartilages and the nasal bones also allows for a thinning in the- upper lateral cartilage area as they "come along" for the ride with the nasal bones as they are medialized, thus adding to the balance of the nose. Figure 7-5E. Pre-op lateral view of severe iatrogenic bony nasal vault underprojection. This patient exhibits a severely under-projected nasal bony vault Figure 7-5F. Post-op frontal view of reconstruction of severe bony nasal vault underprojection with autogenous cartilage sandwich graft augmented with ''tissue clay." Postoperative result

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Figures 7-6A-B. Reconstruction of Bony Nasal Vault Malalignment; 7-6C-F. Reconstruction of Widened Bony Nasal Vault

Figure 7-6A. Pre-op frontal view of reconstruction of bony nasal vault mal-alignment. This patient exhibits malalignment of the nasal bones.This deformity is compounded by the fact that the upper lateral cartilages are anchored to the undersurface of the bones and will additionally be misguided. Figure 7-6B. Post-op frontal view of reconstructed bony nasal vault malalignment. This patient undePvvent the procedures as outlined in Figure 7-2D-F. Postoperatively this patient exhibits a straightened bony nasal vault as well as a corrected midnasal vault due to the fact that the upper lateral cartilages are attached to the undersurface of the nasal bones. Figure 7-6C. Pre-op frontal view of patient exhibiting a bony nasal vault deformity secondary t o widened nasal bones. This patient exhibits a deformity consisting solely of a widened bony nasal vault. Figure 7-6D. Reconstructed result corrected by repositioning t h e nasal bones. Postoperatively this patient exhibits a stronger; thinner; and slightly higher profile. Figure 7-6E. Pre-op 3/4 view of above patient. Figure 7-6F. Post-op 3/4 view of above patient.

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Figure 7-7. Reconstruction of Widened Bony Nasal Vault (Failure of Nasal Bones to Medialize)

Figure 7-7A. Pre-op frontal view of reconstruction of widened bony nasal vault. This patient exhibits a widened bony nasal vault that would not medialize due to a thickened septum. Figure 7-7B. Post-op frontal view of corrected result. This patient underwent the procedures as outlined in Figure 7-3A-C. Postoperatively, this patient exhibits a straightened and thinned bony nasal vault. Figure 7-7C. Pre-op 3/4 view of reconstruction of widened bony nasal vault. This patient exhibits a widened bony nasal vault that would not medialize due to a severely deviated nasal septum. Figure 7-7D. Post-op 3/4 view of corrected result. This patient underwent the procedures as outlined in Figure 7-3D-F Postoperatively this patient exhibits a straightened and thinned bony nasal vault. Figure 7-7E. Pre-op frontal view of reconstruction of widened bony nasal vault. This patient exhibits a widened bony nasal vault that would not medialize due to a bony tissue mass at the upper dorsum. Figure 7-7F. Post-op frontal view of corrected result. This patient underwent the procedures as outlined in Figure 7-3G-I. Postoperatively this patient exhibits a straightened and thinned bony nasal vault.

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Figure 7-8. Reconstruction of Widened Bony Nasal Vault (Failure of Nasal Bones to Medialize)

Figure 7-8A. Pre-op frontal view of reconstruction of widened bony nasal vault. This patient exhibits a widened bony nasal vault that would not nnedialize due to a thickened septum. Figure 7-8B. Post-op frontal view of corrected result. This patient underwent the procedures as outlined in Figure 7-3A-C. Postoperatively, this patient exhibits a straightened and thinned bony nasal vault. Figure 7-8C. Pre-op 3/4 view of same patient. Figure 7-8D. Post-op 3/4 view of same patient. Figure 7-8E. Pre-op frontal view of reconstruction of widened bony nasal vault. This patient exhibits a widened bony nasal vault that would not medialize due to a bony tissue mass at the upper dorsum. Figure 7-8F. Post-op frontal view of corrected result. This patient underwent the procedures as outlined in Figure 7-3G-I. Postoperatively this patient exhibits a straightened and thinned bony nasal vault.

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Figure 7-9. Reconstruction of Contour Deformities

Figure 7-9A. Pre-op 3/4 view of routine primary rhinoplasty. This patient exhibits a slight overprojection of the bony and nnidnasal vault, as well as sonne prominence in the tip. Figure 7-9B. Post-op 3/4 view of concave bony nasal vault deformity. This patient underwent routine cosnnetic rhinoplasty but was left with a residual concave defornnity of the bony nasal vault secondary to partial nasal bone collapse. Figure 7-9C. Corrected revisional result. This patient underwent the procedures as outlined in Figure 7-4D-F. Autogenous cartilage graft corrected the concave defornnity and left the patient with a pleasing and natural profile. Figure 7-9D. Pre-op 3/4 view of routine primary rhinoplasty. This patient exhibits an overprojection of the bony and nnidnasal vault. Figure 7-9E. Post-op 3/4 view of residual convex bony nasal vault deformity. This patient exhibits routine cosnnetic rhinoplasty but was left with a residual convex defornnity of the bony nasal vault. Figure 7-9F. Corrected revisional result. This patient underwent the procedures as outlined in Figure 7-4G-I. Rasping of the offending convexity resulted in a normal-appearing nasal dorsunn.

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M I D D L E N A S A L VAULT

SURGICAL ANATOMY The middle nasal vault centered in the middle-third of the nose is particularly complex because of the relationship of many of its nasal components and their diverse anatomical characteristics. Simplistically one can visualize the middle nasal vault as the septum in the middle acting as a tent pole holding up the sides of the tent that are the upper lateral cartilages, flowing downward to the plane of the face. The superior margins of the upper lateral cartilages are supported by the nasal bones, and their inferior edges lay just under the tip cartilages. Inferiorly the upper lateral cartilages are not rigidly fixated and are free to move in and out from the midline septum, thus forming the kinetic nasal valve. Superiorly the middle nasal vault begins at the junction of the inferior edge of the nasal bones and the superior edge of the upper lateral cartilage. The cartilage lies deep to the bones in this important "nasal bone upper lateral cartilage transition zone" (bone-cartilaginous transition zone) and is held in place by a strong connective tissue matrix that has great importance in revisional rhinoplasty. This bone-to-cartilage articulation is particularly strong and very reactive to trauma. It is a potential source of neoosteogenesis and neochondrogenesis, as well as having a significant propensity to scar with an overabundance of fibroblastic activity. The main body of the middle nasal vault is comprised of the upper lateral cartilages that articulate directly into the dorsal edge of the quadrangular cartilage of the nasal septum. The inferior edge of this articulation is, of course, the internal nasal valve. Much has been written about the judicious handling of these delicate valve tissues, even to the extent of advocating complete avoidance of this area during primary rhinoplasty. This extreme, however, is naive, because many times, especially in a rotational sense, these tissues must be completely disarticulated from each other to allow the nasal tissues to readjust themselves to the new angulation or rotation. The tissues of the nasal valve at the inferior edge of the upper lateral cartilage differs significantly from the superior edge in terms of tissue reactivity. The inferior edge is an area of cartilage to cartilage juxtaposition and the connective tissue at this juncture is less reactive and heals extremely well. During primary rhinoplasty, the intercartilaginous incision meets the incision used to disarticulate the upper lateral cartilage from the dorsal septum. If the tissues are handled judiciously and gently, then only a fine thin scar will be produced, which is a normal

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AESTHETICS The middle nasal vault area should be a smooth and flowing transition area between the upper bony dorsum and the complex tip area. The lateral edges of the middle third of the nose should gently coalesce into the sides of the nose and then onto the anterior plane of the face.

AESTHETIC PATHOLOGY The aesthetic pathology of this region falls into two main categories, concave or convex deformities with the "inverted Y" deformity being considered a subsection of the concave deformities. Most of the nasal tissues that are surgically altered or manipulated during rhinoplasty are unusually forgiving and will withstand many assaults on their integrity before they will react in an unusual way. The connective tissue, however, that makes up the "nasal bone—upper lateral cartilage transition zone" is exquisitely sensitive to manipulation and trauma and will react aggressively to mishandling. If the integrity of this most important connective tissue bridge is lost, then a classic inverted Y deformity will result, which is very difficult to reconstruct successfully. Even more difficulties occur when this connective tissue area is unduly traumatized and becomes irritated. At this point neoosteogenesis, or neochondrogenesis or a combination can occur, causing unsightly bony hard bumpiness in an area that becomes resistant to rasping or even excision. Sometimes multiple procedures are needed to reduce a seemingly innocuous bump in this transistion area once these tissues become irritated. Sometimes even systemic or local judicious injections of steroids are necessary to control the problem. Another manifestation of mishandling these sensitive tissues is true or pseudocyst formation. This particular problem is even more difficult to remedy due to lack of excellent exposure. External rhinoplasty approach and sometimes even external incisions overlying the offending cyst are necessary. The other main areas of aesthetic pathology that present themselves are contour irregularities overlying the upper lateral cartilages. These can be concave in nature causing a bowing in of the cartilages that are unsightly and can alter the overall curvature of the nose, giving the length of the nose a pseudo-twist appearance. Irregular localized concavities exist, as do convexities presenting as bulkiness overlying the entire span of the upper lateral cartilages or as isolated lumps and bumps.

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Hypertrophic scar or tissue formation in the area of the inferior margin of the upper lateral cartilages rarely causes aesthetic deformities, even though significant physiologic valve problems can exist. This is due to the fact that there is significant mobility in this area of the nose, and hypertrophic tissue will tend to bend the internal tissues inwardly, and not until it is excessive will the tissue become actually convex enough to cause an aesthetic problem.

TECHNICAL CONCEPTS OF RECONSTRUCTION The "bone-cartilage transition zone" should be altered minimally and very gently. Exposure of the nasal bones should begin with the periosteal elevator coming down on the nasal bones, and never into the area where the upper lateral cartilages articulate into the bones. Rupture or dehiscence of this connective tissue band allows the upper lateral cartilages to lose support and fall into the nasal vault, giving a drop-off deformity on the dorsum of the nose and eventually a full fledged inverted-Y deformity. This will also set up subsequent overactive healing deformities as described above. Exposure of the upper lateral cartilages should be adequate to see the dorsal edges readily and throughout the entire scope of their relationship with the septum. Lateral exposure should be limited to the particular operation necessary. If there is a contour deformity along the lateral side of the upper lateral cartilage, then exposure of this extent of cartilage is necessary to adequately prepare the area for surgical alteration.

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Figure 8-1 • Reconstruction of Convex Deformities of the Superior Middle Nasal Vault (Bone-Cartilaginous Transitional Zone)

Figure 8-1 A. Convex deformities of the bone-cartilaginous transition zone. Bone-cartilaginous transition zone convex defornnities include (I) cysts, pseudo-cysts; (2) scar tissue; (3) neoosteogenesis and (4) neochondrogenesis or a connbination. Often tinnes it is innpossible to deternnine preoperatively the exact histologic nature of the convex defornnity Newly fornned bone or cartilaginous tissue in the region of the bone-cartilage transition zone has to be removed cleanly and completely to obviate occurrence of new formations. Figure 8-1B. Exposure of middle nasal vault for excision of convex deformity due to scar tissue, neoosteogenesis or neochondrogenesis. Sharp disarticulation of upper lateral cartilage from septum begins the exposure. Figure 8-1C. Continuation of exposure with medial osteotomy. The dissection continues with a medial osteotomy through the center of the deformity hugging the medial edge of the septum. Figure 8-1D. Excision of convex deformity. Upper. A serrated right-angled scissors begins the excision into the upper lateral cartilage. Lower.The chisel is then reinserted into the same plane of dissection and completes the excision.This technique leaves as clean a dissection as possible without leaving fragments of tissue or jagged mucosal edges to cause subsequent problems. Figure 8-1E. Residual defect. The above dissection and excision has left the illustrated defect. Figure 8-1F. Reconstruction of residual defect. A cartilage graft is used to reconstruct the defect. Figure 8-1G. Cyst or pseudocyst presenting in bone-cartilaginous transition zone. Cysts in this area usually present at the junction of the upper lateral cartilage and nasal bone. Figure 8-1H. Direct excision of cyst. Upper Incision overlying the cyst is the most direct and expedient maneuver to solve this problem. Lower Direct excision of the cyst is accomplished with careful sharp dissection. Figure 8-11. Closure. The incision is closed directly often with a negligible resultant scar Laser can be used to enhance the external appearance of the scar

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Figure 8-2. Reconstruction of Convex Deformities of the Middle Nasal Vault

Figure 8-2A. Convex deformity overlying upper lateral cartilage. Convex bulk deformity of the middle nasal vault secondary to scar tissue formation overlying upper lateral cartilage. Figure 8-2B. Convex deformity overlying upper lateral cartilage. Disarticulation of the upper lateral cartilage begins the dissection. Figure 8-2C. Excision of scar overlying upper lateral cartilage. Inferior edge of upper lateral cartilage is pulled inferiorly tensing the upper lateral cartilage. Sharp-scissors dissection via a routine intercartilaginous incision completes the dissection.The nose is then taped and dressed in a normal manner; without additional sutures. Figure 8-2D. Convex deformity secondary to inadequate trimming of medial edge of upper lateral cartilage. Inadequate trimming of medial edge of upper lateral cartilage leaves a convex midline deformity Figure 8-2E. Excision of medial edge of upper lateral cartilage. Deformity is corrected by appropriate trimming of the medial edge of the upper lateral cartilage. Figure 8-2F. Corrected result. Upper lateral cartilage is now at the correct height, leaving a smooth dorsal contour Figure 8-2G. Convex deformity secondary to scar tissue formation at the septal upper lateral cartilage junction. Scar tissue formation at junction of septum and upper lateral cartilage usually causes a soft but noticeable convex deformity A "polybeak" deformity has a similar etiology but is also due to excess, thickened skin in this area. Figure 8-2H. Conversion of convex to concave deformity by excision of scar tissue and medial edge of upper lateral cartilage. Upper. Excision of scar tissue is accomplished with a straight, sharp scissors.The attached associated medial edge of the upper lateral cartilage is also excised, thus converting a convex deformity into a clean, smooth concave deformity Lower. Defect left after excision of scar tissue. Figure 8-21. Reconstruction and corrected result. Upper Defect is filled in with autogenous cartilage graft. Lower. Corrected result.

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Figure 8-3. Reconstruction of Concave Deformities of the Middle Nasal Vault

Concave deformities in this nniddle vault area are a function of either excess upper lateral cartilage excision and/or disruption of their intrinsic support.To understand the genesis of the collapse, we must examine the support mechanisms of the upper lateral cartilage. The upper lateral cartilages derive most of their support medially from their attachment with the septum, and superiorly from their connections just underneath the nasal bones.There is some support laterally that is derived from the soft tissue envelope surrounding the upper lateral cartilage. By design, the caudal edge offers no support because of its kinetic function as the internal nasal valve. Concave deformities can occur anywhere along the upper lateral cartilage and at the superior and inferior junctions with the adjacent nasal tissue. Superiorly if the connective tissue is ruptured or disarticulated, the upper lateral cartilage can collapse into the nasal vault, causing depressions along the superior edge. Figure 8-3 A. Support mechanisms of the upper lateral cartilage. The three areas of support for the upper lateral cartilage in order of importance are: (I) superior attachments to the undersurface of the nasal bones; (2) medial connection to the dorsal septum.This attachment is physically strong but is often disrupted during primary or revisional rhinoplasty; (3) lateral soft-tissue envelope support. Figure 8-3B. Concave defect secondary to over resection of medial edge of upper lateral cartilage. Upper. Overzealous resection during primary rhinoplasty will cause crevices and concavities in the midline of the nasal dorsum. If the resection is severe it will actually depress the entire upper lateral cartilage. Lower. Scar tissue and adjacent upper lateral cartilage are resected en bloc with a serrated right-angled scissors, leaving a clean smooth depression. Figure 8-3C.Autogenous cartilage graft reconstruction. A crushed septal or auricular cartilage graft is placed into a pocket overlying the concavity and either sutured into place or for more security a cartilage adhesive is used. Figure 8-3D.True "inverted-Y" deformity and "inverted-V" deformity. The classic "inverted-Y" deformity is in actuality a problem that stems from a collapse of the upper lateral cartilages secondary to a lack of support, coupled with lateralization and partial collapse of the nasal bones after osteotomy This is associated with a midline nasal bone separation. The etiology ofthe"inverted-V" deformity is simply a collapse of the upper lateral cartilages secondary to disruption of their superior support mechanism.There is no deformity of the nasal bones; thus they are proportionate to the rest of the face. UpperJhe classic "inverted-Y" deformity is so named because the leg of the Y is due to the midline nasal bone separation, and the top of the Y is due to collapse of the superior edge of the upper lateral cartilage.Thus, by definition, this deformity must include a disproportionate widening of the bony nasal vault. Lower.The "inverted-V" deformity includes only a superior collapse of the upper lateral cartilages.The etiology of this is usually a disruption of the support fibers connecting the upper lateral cartilages to the undersurface of the nasal bones during separation of the soft-tissue envelope with a periosteal elevator during rhinoplasty Figure 8-3 E. Etiology of "inverted-Y" deformity. This view shows the widened nasal bones with a midline separation, combined with a collapse of the upper lateral cartilages bilaterally Figure 8-3 F. Etiology of "inverted-V" deformity. Upper Front view showing normally spaced nasal bones with bilateral collapse of superior edge of upper lateral cartilages. Lower Lateral view. Figure 8-3G. Reconstruction of "inverted-Y" deformity. The first step of this reconstruction is to perform full medial and lateral osteotomies to reposition and narrow the nasal bones. Figure 8-3 H. Cartilage graft reconstruction of "inverted-Y and inverted-V" deformity. Approach to this reconstruction is through an intercartilaginous incision, with adequate exposure and undermining to incorporate the lateral extent of the deformity A crushed cartilage graft shaped to contour to the collapsed V-shape is formed and placed into the appropriate area, as shown.To reconstruct an "inverted-Y" deformity one must include the osteotomies and the cartilage grafting. For an "inverted-V" reconstruction, only the grafting is usually necessary Figure 8-3i.Touch-up reconstruction. If the cartilage graft doesn't fit smoothly or if there is some concavity evident after placement of the graft, then either tissue clay or"GelToam," or similar filler is used to soften the reconstructed area.

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Figure 8-4. Reconstruction of Concave Deformities of the Inferior Middle Nasal Vault (Upper Lateral Cartilage— Tip Cartilage Transition Zone)

Figure 8-4A. Concave deformit/ of the inferior middle nasal vault. This severe concave deformity is due to overresection of the inferior edge of the upper lateral cartilage combined with overresection of the cephalic border of the tip cartilage. Scar tissue has bridged the gap between these two tissue planes, exacerbating the deformity. Figure 8-4B.Approach to tip cartilage and attached scar. Through a rim incision, the tip cartilage is exposed by undermining the tissues superficial and deep to the cartilage. Figure 8-4C. Excision of tip cartilage and scar. Upper.Jhe tip cartilage is exposed until scar tissue is visualized cephalic to the cartilage. Lower.Jhe tip cartilage and scar are excised en-bloc. Figure 8-4D.Approach to upper lateral cartilage and attached scar. Through an intercartilaginous incision, the upper lateral cartilage is exposed. Figure 8-4E. Excision of inferior edge of upper lateral cartilage and scar. Upper.Jhe upper lateral cartilage is sharply excised. Lower.The excision is completed medially with a right-angled scissors. Figure 8-4F. Reconstruction of tip. Tip cartilage graft is designed and placed into an appropriate area through a rim incision. Cartilage adhesive helps maintain position and stability of graft. Figure 8-4G. Reconstruction of upper lateral cartilage. Upper lateral cartilage graft is designed and placed into appropriate area through an intercartilaginous incision. Figure 8-4H. Reconstruction of upper lateral cartilage. Morselization of the graft at the upper lateral cartilage junction is suggested to smooth the transition zone. Cartilage adhesive helps maintain position and stability of graft. Figure 8-41. Corrected result. The two grafts act to restore function and shape to the reconstructed area.

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Figure 8-5. Reconstruction of Convex Deformities of the Superior Middle Nasal Vault (Bone-Cartilaginous Transition Zone)

Figure 8-5A. Pre-op 3/4 view of postsurgical convex deformity of the superior middle nasal vault. This patient exhibits a small dorsal cartilaginous and bony convex deformity secondary to primary rhinoplasty with injury and subsequent neoosteogenesis in the bone-cartilaginous transition zone. Figure 8-5B. Post-op 3/4 view of reconstructed convex deformity of the superior middle nasal vault. This patient underv/ent a direct excision of deformity with sharp chisel. Light rasping smoothed the contour thus there was no need for direct en-bloc excision in this case. Figure 8-5C. Pre-op 3/4 view of postsurgical convex deformity of the superior middle nasal vault. This patient exhibits a large area of dorsal cartilaginous and bony convex deformity secondary to primary rhinoplasty with injury and subsequent neoosteogenesis and neochondrogenesis in the bone-cartilaginous transition zone. Figure 8-5D. Post-op 3/4 view of reconstructed convex deformity of the superior middle nasal vault. This patient underwent a direct excision of deformity with sharp chisel. Light rasping and a small superficial thinned cartilaginous graft smoothed the contour; thus there was no need for direct en-bloc excision in this case. Figure 8-5E. Pre-op 3/4 view of convex deformity of the superior middle nasal vault. This patient exhibits a convex deformity of the superior middle nasal vault. Figure 8-5F. Post-op 3/4 view of reconstruction of convex deformity with en-bloc dissection and cartilage graft. This patient undenA/ent the procedures as outlined in Figure 8-1A-F. His deformity necessitated the en-bloc dissection.The postoperative result exhibits a stronger; more masculine, yet smooth dorsal profile.

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Figure 8-6A—B. Reconstruction of Cyst Presenting in Bone-Cartilaginous Transition Zone; 8-6C—D. Reconstruction of Convex Scar Deformity Overlying Upper Lateral Cartilages; 8-6E—R Reconstruction of Convex Deformity at Septal Upper Lateral Cartilage Junction

Figure 8-6A. Pre-op 3/4 view of cyst presenting in bone cartilaginous transition zone. This patient exhibits a cyst in the very sensitive bone cartilaginous transition zone. Figure 8-6B. Post-op 3/41 view after cyst removal. This patient undenA/ent the procedures as outlined in Figure 8-1 G-l. Figure 8-6C. Pre-op frontal view of patient presenting with a convex scar deformity overlying the upper lateral cartilages. This patient exhibits a deformity consisting solely of scar tissue formation directly over the upper lateral cartilages bilaterally Figure 8-6D. Reconstructed result corrected by scar excision. This patient underwent the procedures as outlined in Figure 8-2A-C. Postoperatively this patient exhibits a smoother dorsal plane overlying the upper lateral cartilages, which blends into both the bony nasal vault and the lower 1/3 of the nose. Figure 8-6E. Pre-op 3/4 view of patient exhibiting a combination deformity of scar tissue and residual cartilage at the septal upper lateral cartilage junction. This patient exhibits a convex deformity of the septal upper lateral cartilage junction.The deformity consists of scar tissue and residual cartilage. Figure 8-6F. Post-op 3/4 view of above patient. This patient underwent the procedures outlined in Figure 8-2G-I.The deformity was excised as described, and a cartilage graft was placed to hide the defect, and in this case afforded a stronger more natural dorsal profile.

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Figure 8-7. Reconstruction of Scar Tissue Deformity at the Septal Upper Lateral Cartilage Junction Without Grafting

Figure 8-7A. Pre-op frontal view of routine primary rhinoplasty. This patient exhibits a slight overprojection of the bony and nnidnasal vault, as well as sonne pronninence in the tip. Figure 8-7B. Post-op Frontal view of scar tissue deformity at the septal upper lateral cartilage junction. This patient underwent routine cosmetic rhinoplasty but was left with a residual scar tissue deformity at the septal upper lateral cartilage junction. Figure 8-7C. Corrected revisional result. This patient underwent the procedures as outlined in Figure 8-2G-H. However the excision was done exactingly without the need for autologous cartilage grafting. Figure 8-7D. Pre-op lateral view of same patient. Figure 8-7E. Post-op lateral view of scar tissue deformity of same patient. Figure 8-7F. Corrected revisional result of same patient.

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Figure 8-8. Reconstruction of Convex Deformity Secondary to Inadequate Trimming of Medial Edge of Upper Lateral Cartilage

Figure 8-8A. Pre-op frontal view of reconstruction excessive medial edge of upper lateral cartilage. This patient exhibits postsurgical deformity of the middle nasal vault secondary to inadequate trimming of the medial edge of the upper lateral cartilage. Figure 8-8B. Post-op frontal view of corrected result. Simple trimming of the redundant upper lateral cartilage, as shown in Figure 8-2D, gives a more pleasing and smooth profile, which is evident from all angles. Figure 8-8C. Pre-op Lateral view of same patient. Figure 8-8D. Post-op lateral view of same patient. Figure 8-8E. Pre-op 3/4 view of same patient. Figure 8-8F. Post-op 3/4 view of same patient.

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Figure 8-9. Reconstruction of Concave Defect Secondary to Oversection of Medial Edge of Upper Lateral Cartilage

Figure 8-9A. Pre-op 3/4 view of routine primary rhinoplasty. This patient exhibits a slight overprojection of the bony pronninence in the tip. Figure 8-9B. Post-op 3/4 view of concave defect secondary to overresection of medial edge of upper lateral cartilage bilaterally. This patient underwent routine cosmetic rhinoplasty but was left with a residual concave deformity at the septal upper lateral cartilage junction due to overresection of the medial edges of the upper lateral cartilages bilaterally Figure 8-9C. Corrected revisional result. This patient underwent the procedures as outlined in Figure 8-3B-C. She now has a strong, straight natural profile. Figure 8-9D. Pre-op 3/4 view of same patient. Figure 8-9E. Post-op 3/4 view of same patient. Figure 8-9F. Corrected revisional result of same patient.

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Figure 8-10. Reconstruction of "inverted Y andV* Deformities

Figure 8-IOA. Pre-op frontal view of "inverted-Y" deformity. This patient exhibits a postoperative "inverted-Y" deformity. Figure 8-1 OB. Post-op frontal view of reconstructed "inverted-Y" deformity. This patient underwent the procedures as outlined in Figure 8-3G-L She now has a smooth, pleasing dorsal contour Figure 8-1OC. Pre-op 3/4 view of same patient. Figure 8-1OD. Post-op 3/4 view of same patient. Figure 8-1OE. Pre-op 3/4 view of **inverted-V" deformity. This patient exhibits a postoperative "inverted-V" deformity. Figure 8-1 OF. Post-op 3/4 view of corrected revisional result. This patient underwent the procedures, as outlined in Figure 8-3H-I. Since her nasal bones were intact and had not shifted, she did not require osteotomies as part of her reconstruction.

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Figure 8-1 L Reconstruction of Pseudo "Inverted-V" Deformity

Figure 8-11 A. Pre-op frontal view of pseudo "inverted-V" deformity. This patient exhibits a postoperative pseudo "inverted-V" deformity. Although she has, at first glance, a noticeable inverted-V-shape defornnity, the etiology of her problenn is not due to collapse of the upper lateral cartilages but to a redundancy of tissue in this area. Figure 8-11B. Pre-op lateral view of same patient. Figure 8-11C. Pre-op 3/4 view of same patient. Figure 8-11D. Post-op frontal view of same patient. After adjusting the excess upper lateral cartilage tissue, the nose now appears natural and proportionate to the face, without any hint of an "inverted-V" defornnity Figure 8-11E. Post-op lateral view of same patient. Figure 8-11F. Post-op 3/4 view of same patient.

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Figure 8-12. Reconstruction of Concave Deformity of the Upper Lateral Cartilage-Tip Cartilage Transition Zone

Figure 8-12A. Pre-op frontal view of concave deformity of the right upper lateral cartilage-tip cartilage transition zone. This patient exhibits postsurgical deformity of the right middle nasal vault, secondary to overzealous trimming of the upper lateral cartilage, combined with excessive resection of the cephalic border of the right-tip carilage. Figure 8-12B. Post-op frontal view of corrected result. This patient underwent the procedures outlined in Figure 8-4A-I.The dual cartilage grafts fill in the concave defect and restore the nose to a more natural shape. Figure 8-12C. Pre-op lateral view of same patient. Figure 8-12D. Post-op lateral view of same patient. Figure 8-12E. Pre-op 3/4 view of same patient. Figure 8-12F. Post-op 3/4 view of same patient.

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Figure 8-13. Reconstruction of Concave Deformity of the Upper Lateral Cartilage-Tip Cartilage Transition Zone

Figure 8-13 A. Pre-op frontal view of bilateral concave deformity of the upper lateral cartilage—^tip cartilage transition zone. This patient exhibits a bilateral postsurgical deformity of the middle nasal vault, secondary to overzealous trimming of the upper lateral cartilages, combined with excessive resection of the cephalic border of the tip cartilages. Figure 8-13B. Post-op frontal view of corrected result. This patient underwent the procedures outlined in Figure 8-4A-l. Although a bilateral repair was performed, the left side was significantly worse, and adjustments had to be made intraoperatively to gain a symmetric result. Figure 8-13C. Pre-op lateral view of same patient. Figure 8-13D. Post-op lateral view of same patient. Figure 8-13E. Pre-op 3/4 view of same patient. Figure 8-13F. Post-op 3/4 view of same patient.

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CHnPTI-n SEPTUM

SURGICAL

ANATOMY The septum throughout its entire superiodorsa! and inferiocaudal borders influences the contour and shape of the nose. The inferior border impacts on functional disease of the nose, as does the posterior border. Not only is there a significant influence by this very important structure on the form and shape of the external nose, but also the septum supplies the bulk of material generally used to reconstruct the revisional defects.

AESTHETICS Although the aesthetics of the actual septum are not terribly important, the straightness and angulation of the septum influences almost every part of the nose.

AESTHETIC

PATHOLOGY Starting at the superior-most aspect of the septum, just deep to the nasal bones, the septum, if it is widened or twisted, will influence the alignment of the nasal bones. Deformities of the septum in this area accounts for the inabilty to medialize and straighten the nasal bones. If the septum is overly high at this point this will present as a dorsal bump strictly due to the nasal septum and unrelated to the nasal bones. At the point that the septum confluences with the upper lateral cartilages, if the septum is twisted, too high or too low, this will influence the contour and shape of this midportion of the nose.

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Figure 9-1 .Septal Reconstruction

UPPER BONY DORSUM: Figure 9-IA.Twisted septum deformity. Twisted nasal septum just deep to the nasal bones nnust be corrected to allow for proper nnedialization and alignnnent of the nasal bones. Figure 9-1 B.Thickened septum deformity. Upper: After osteotonny, the thickened septunn does not allow nnedialization of the nasal bones. Lower: Sharp chisel excision of thickened septunn allows for proper medalization of nasal bones. Figure 9 - I C . Heightened septum deformity. Upper: Septunn that is too high will cause a convex contour deformity of the upper dorsum. Lower: Septum must be trimmed via serrated scissors or chisel to match the height of the nasal bones.

MiDCARTILAGINOUS DORSUM: Figure 9-1 D.Twisted or thickened septum deformity of middorsum. Middorsal septal deflections will cause twisting of the upper lateral cartilages and must be corrected to straighten the midportion of the nose. Figure 9-1E. Excision of heightened dorsal septum deformity. Heightened dorsal septum of the midportion of the nose will cause convex contour deformites. They must be corrected via excision to match the height of the upper lateral cartilages. Figure 9-IF.Concave middorsal septum deformity. Upper: Middorsal septum that is too low will allow the upper lateral cartilages to sink inward, causing a concavity Lower: Correction of concavity is easily reconstructed with a cartilage graft. Caudal septum: upper portion/ mid portion/ low portion Figure 9-1G. Influence of upper caudal septum. The upper caudal septum lies just below the tip cartilages and can influence their symmetry as well as their projection.The proper amount of septum must exist below the tip cartilages to support them in their proper projection.The septum must also be straight in order for the tip cartilages to lie symmetrically Figure 9-1H. Influence of midcaudal septum. The midcaudal septum can influence the legs and body of the tip cartilages, causing asymmetry in the midcolumella region. Straightening of this area is essential for symmetry of the columella, and partial resection of the feet of the tip cartilages may be necessary to make this area even. Figure 9-11. Influence of inferior caudal edge of septum. The inferior caudal edge of the septum blends into the nasal spine and influences the projection and straightness of this part of the base of the columella, judicious straightening of the septum, as well as partial or total excision of the spine, will allow for proper projection and symmetry of this area.

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Figure 9-2. Reconstruction of Septal Deformities of the Upper Bony Dorsum

Figure 9-2A. Pre-op frontal view of twisted septum deformity. This patient exhibits a twisted septum deformity (Figure 9-1 A) that is not allowing for proper medialization and alignment of the nasal bones. Figure 9-2B. Post-op frontal view of reconstructed twisted septum deformity. This patient underwent a direct resection of the offending deviated septum and subsequent realignment of the nasal bones. Figure 9-2C. Pre-op 3/4 view of thickened septam deformity. This patient exhibits a thickened septum deformity (Figure 9-1B) that is not allowing for proper medialization and alignment of the nasal bones. Figure 9-2D. Post-op 3/4 view of reconstructed thickened septum deformity. This patient underwent a direct excision of thickened septum with sharp chisel. Realignment of the nasal bones was then performed (Figure 9-1B). Figure 9-2E. Pre-op 3/4 view of heightened septum deformity. This patient exhibits a heightened septum deformity Figure 9-2F. Post-op 3/4 view of reconstructed heightened septum deformity. This patient underwent a direct excision of the heightened septum by sharp chisel dissection (Figure 9-1C).

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Figure 9-3. Reconstruction of Septal Deformities of the Mid Cartilaginous Dorsum

Figure 9-3 A. Pre-op 3/4 view of heightened and twisted septum deformity of the mid-cartilaginous dorsum. This patient exhibits a heightened septunn defornnity (Figure 9-1D) of the nnid-cartilaginous dorsunn. Figure 9-3B. Post-op 3/4 view of reconstructed heightened and twisted septum deformity. This patient underwent a direct resection of the offending deviated septunn (Figure 9-1E). Figure 9-3C. Pre-op frontal view of thickened septum deformity. This patient exhibits a thickened septum deformity (Figure 9-1D) of the mid-cartilaginous dorsum. Figure 9-3D. Post-op frontal view of reconstructed thickened septum deformity. This patient underwent a direct excision of thickened septum with sharp-angled scissors (Figure 9-IE). Figure 9-3E. Pre-op frontal view of twisted septum deformity of the mid cartilaginou dorsum. This patient exhibits a twisted septum deformity that malaligns the entire middle third of the nose. Figure 9-3F. Post-op frontal view of reconstructed twisted septum deformity. This patient underwent a direct excision of the twisted septum by sharp-angled scissors dissection (Figure 9-1E).

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Figure 9-4. Reconstruction of Mid Dorsal Concave Septal Deformities

Figure 9-4A. Pre-op frontal view of septal concavity. This patient exhibits a significant septal concavity (Figure 9-1F). Figure 9-4B. Post-op frontal view of reconstructed septal concavity. This patient underwent a dorsal cartilage graft to correct the concavity (Figure 9-1F). Figure 9-4C. Pre-op 3/4 view of same patient. Figure 9-4D. Post-op 3/4 view of same patient. Figure 9-4E. Pre-op 3/4 view of septal concavity. This patient exhibits a significant septal concavity (Figure 9-1F). Figure 9-4F. Post-op 3/4 view of reconstructed septal concavity. This patient underwent a dorsal cartilage graft and a tip plasty to correct the concavity (Figure 9-IF).

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fflfflll ulllll ILII IU COLUMELLA

SURGICAL

ANATOMY The columella is a relatively complex anatomical structure, which, as its name and central location at the base of the nose implies, is a column of midline tissue. This combination of cartilage, muscle, skin, and soft tissue contributes not only significant support to the midline nasal structures but also is an important aesthetic component to the midline nose. It is composed of membranous soft tissue that starts at the base of the nose, at the junction of the lip, and continues superiorly, encasing the feet of the tip cartilages. It then blends into the nostril superiorly, actually forming the medial edge of the nostril. At the base of the columella the feet of the lower lateral cartilages bow outward, giving the columella broadness to its base and then slimming as it extends superiorly. The important cartilaginous components of the columella are composed of the medial portions of the lower lateral cartilages, more specifically the body, legs and feet. The caudal aspect of the septum also contributes and blends into the columella, actually fitting into the membranous tissue.

AESTHETICS The primarily important aesthetic component of the columella is straightness. The eye quickly notices any angulation of the columella, and these distortions are very bothersome to the symmetry of the nose and, in turn, the face. The membranous columella should be smooth bilaterally, with the base being wider then the column and then thinning in the midportion of the column, widening laterally as the columella becomes the medial portion of the nostril. Smoothness and symmetry are of utmost importance in defining the aesthetic characteristics of the columella. The slightly angular superio-inferior projection of the columella is extremely important in defining good nasal aesthetics and should drop slightly below the alar soft-tissue wings. Excessive distance between the inferior edge of the alar and the columella causes an untoward droopiness, and too little causes an equally unsightly retraction. The width of the columella should be delicate and symmetrical in the midportion and flow evenly and extend laterally both at the top and bottom of the column of tissue to blend into the nostril. There should be a smooth, continuous contour, without notching or contour defects.

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AESTHETIC PATHOLOGY From the frontal view, the most common distortion of the columella relates to straightness, which is determined primarily by the caudal septum and secondarily by the feet, legs, and body of the tip cartilages. Any aberration of these cartilaginous components, either alone or in conjunction with one another, will skew the columella and undermine the aesthetic integrity of this region of the nose. Two distinct entities of twisted columella are examined. In the first example, the caudal septum is deviated and subluxated off the premaxilla. In the second example, the columella is twisted because one or both feet of the tip cartilages are asymmetrically enlarged and/or twisted, causing a concomitant deformity in the columella. These entities can exist alone or in combination. From a lateral or angular view the lightly slanted superio-inferior angle of the columella with the rest of the nose is extremely important. Excessive cartilaginous or soft tissue will cause the columella to droop and hang, leaving unsightly tissue visible, whereas too little cartilage or soft tissue causes an equally unsightly retraction of the columella. The columella also contributes to the intrinsic support and is a major determinant of tip projection. Manipulation of the columella can aid in decreasing tip projection. In this context, it is noteworthy that the soft tissues of the columella alone contribute a significant amount to the overall tip support and can be manipulated to address this area as well. Cartilaginous components of the columella usually will have to be readjusted, but the intrinsic strength of the membranous columella alone is quite strong and lends a significant amount of support to the tip of the nose.

TECHNICAL CONCEPTS OF RECONSTRUCTION Most deformities and defects in the columella are readily repaired with a minimal amount of reconstructive defect and with excellent results. The key component to this success is to make the correct diagnosis.

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Figure 10-1 • Reconstruction of Twisted Columella Secondary to Caudal Septal Deviation

Figure 10-1 A.Twisted columella—base view. The base view shows skewed columella secondary to significant deviation of caudal septunn exacerbated by subluxation off the prennaxilla. Figure 10-1 B.Twisted columella—interior view. Angled interior view shows degree of caudal deflection. If the deflection is nnininnal to nnoderate and is due to a relative excess of caudal septum, then direct intranasal excision of the deflected caudal septum will usually be enough to effect the repair If not, then direct attack on the caudal septum with reinsertion of the straightened septum into a caudal mucosal pocket will be necessary Figure 10-1C. Exposure of caudal septum. Caudal septum is exposed by creating and reflecting a left anterior mucoperichondrial tunnel. Figure 10-1D. Exposure of caudal septum (continued). A right anterior mucoperichondrial tunnel is created, affording full exposure of the anterior caudal septum. Figure 10-1E. Excision of deviated caudal septum. After full exposure is gained through bilateral mucosal tunnels, the deflected portion of the septum is excised enbloc. Figure 10-1F. Reconstruction of excised septum. En-bloc septal cartilage is straightened as needed and glued. Figure 10-1G. Reinsertion of reconstructed septum. Reconstructed septum is placed into mucoperichondrial tunnel. Additional glue may be inserted between the cartilage and the mucosa bilaterally This may be especially helpful if the reconstructed septum is in many pieces and needs additional support. Figure 10-1H. Suturing of mucosal tunnels. After the septum is reinserted and glued into place, the mucosa is approximated with a continuous quilting stitch to gain additional support and closure to the reconstruction. Figure 10-11. Corrected result. Base view shows septum in the midline and a straightened columella.

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Figures 10-2A-C. Reconstruction of Twisted Columella Secondary to Foot of Tip Cartilage Deformity; I 0 - 2 D - I . Reconstruction of Hanging Columellae

Figure 10-2A.Twisted columella—base view. Base view shows skewed columella secondary to significant asynnnnetry and deviation of the foot of the right-tip cartilage.This enlarged right foot causes the colunnella to skew in the opposite direction and also narrows the right nostril. Figure 10-2B. Exposure and excision of foot of right-tip cartilage. Correction of twisted and asymnnetric foot of right-tip cartilage is started by cutting into the columella skin directly over the foot. A small hook aids exposure.The curled, excess cartilage is directly excised. Since the feet do not impart a particularly important aspect of tip or columella support, then direct excision without reinsertion of a stabilizing cartilaginous element is all that is necessary If in any particular patient the support of the tip is compromised by this maneuver then reinsertion of a support graft would be indicated. Figure 10-2C. Corrected result. Base view now shows symmetrical nostrils with a straight columella. Figure I0-2D. Lateral view o f hanging columella." The classic "Hanging Columella" is due to an excess of (I) cartilage of the legs and feet of the tip cartilages, (2) inferior caudal septal cartilage, and (3) membranous columella skin and subcutaneous tissue. All of these entities can exist alone or in combination. Successful repair of this deformity must include proper trimming of each entity Figure 10-2E.''Hanging columella'' due to excessive width and bulk of legs and feet of tip cartilages. Bulky and excessive tip cartilages particularly in a superio-inferior direction, contributes to a thickened, droopy columella. Figure 10-2F.''Hanging columella" due to excessive inferior caudal septum. Excessive septal cartilage that protrudes in an inferio-caudal direction will push the columella inferiorly contributing to this deformity Figure I0-2G. Reconstruction of "hanging columella" by direct excision of inferior edge of tip cartilage and inferio-caudal septum. Repair of hanging columella is accomplished after the surgeon performs a transfixtion incision and directly excises the extraneous bulk of the body legs, and feet of the tip cartilages.The protruding inferio-caudal septum is also excised as needed. Figure IO-2H.Trimming of membranous columella. Trimming of the extraneous membranous columella skin and subcutaneous tissue to match the newly formed columella is then performed.The edges of the mucosa overlying the septum and the membranous columella are then sutured to effect the closure. Figure 10-21. Corrected result. The appropriate amount of columella is now evident from the lateral view.

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Figure 10-3. Reconstruction of Retracted Columella (1^2^ 3"^)

Figure 10-3A. First degree deformity. The opposite of the "hanging colunnella" is the "retracted" columella.The first-degree deformity can be caused by (I) foreshortened feet and legs of the tip cartilages in both length and width and (2) short or retracted nasal spine. In addition, there is usually a minimal-to-moderate loss of membranous soft tissue. If the lack of membranous soft tissue is severe, and will not allow the creation of a pocket for reconstruction, then the retraction would be defined as a third-degree deformity (Figures 3G-l).These entities can be congenital or iatrogenic, and can exist alone or in combination. Figure 10-3B. Cartilaginous plumping graft reconstruction. The correction of this deformity begins with the creation of a soft-tissue pocket within the membranous columella. A plumping cartilage graft is then fashioned and placed within the pocket. Alternatively soft-tissue augmentation may also be used, depending on the severity of the deformity The pocket is then closed primarily Figure 10-3C. Corrected result. The graft adjusts for the loss of tissue and brings the columella down into a more normal position. Figure 10-3D. Second-degree deformity. Second-degree deformity is defined as a more extensive degree of retraction and is due to any or all of the problems causing a first-degree deformity but, in addition, there is a deficiency in the caudal quadrangular cartilage of the septum. Figure 10-3E. Harvesting of auricular cartilage graft. In preparation for the reconstruction, a cartilage graft is harvested from the ear Figure 10-3F. Cartilage graft reconstruction. Assuming adequate membranous columella tissue, the surgeon places the septal cartilage graft between a prepared tunnel within the membranous columella. An alternative approach is through the upper midgingival area of the mouth. Figure 10-3G.Third-degree deformity. The definition of third-degree columella retraction deformity includes significant loss and scarring of membranous columella skin, usually associated with a loss of septal cartilage. Figure 10-3H. Placement of composite auricular graft. The reconstruction begins with harvesting a full thickness composite auricular graft, with skin on both sides of the cartilage. A transfixtion incision releases the retraction in the columella, and all scarred tissue in this area is primarily excised.The graft is then designed and sized. Figure 10-31. Corrected result. The composite graft is then sutured into place, replacing the missing cartilaginous and soft-tissue components.

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Figure 10-5 A - D . Reconstruction of Twisted Columella Secondary to Foot of Tip Cartilage Deformity I0-5E-F. Reconstruction of Hanging Columella Secondary to Excess Cartilage of the Legs and Feet of the Tip Cartilages

Figure I0-5A. Pre-op frontal view of foot of tip cartilage deformity. This patient exhibits a significant defornnity of her feet of the tip cartilages bilaterally. It is obvious fronn the front view but very distracting fronn the 3/4 view. (Figure 10-2E-F). Figure I0-5B. Post-op frontal of foot of tip cartilage deformity. This patient underwent a bilateral excision of the feet of the tip cartilages (Figures 10-2A-C). She now has a much nnore natural look to the entire bottonn 1/3 of the nose. Figure I0-5C. Pre-op 3/4 view of same patient. Figure I0-5D. Post-op 3/4 view of same patient. Figure 10-5E. Pre-op 3/4 view of hanging columella secondary to excess cartilage of the legs and feet of the tip cartilages. This patient exhibits a significant hanging colunnella defornnity secondary to excess cartilage of the legs and feet of the tip cartilages. (Figures 10-2D-E). Figure I0-5F. Post-op 3/4 view of reconstructed hanging columella deformity. This patient underwent a bilateral trinnming of the feet and legs of the tip cartilages (Figure 10-2G). She now has a much more natural shape to the columella.

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Figure 10-6. Reconstruction of Hanging Columella Secondary to Excess Cartilage of the Legs and Feet of the Tip Cartilages

Figure 10-6A. Pre-op lateral view of hanging columella secondary to excess cartilage of the legs and feet of the tip cartilages. This patient exhibits a significant hanging colunnella deformity secondary to excess cartilage of the legs and feet of the tip cartilages (Figures 10-2D-E). Figure I0-6B. Post-op lateral view of reconstructed hanging columella deformity. This patient underwent a bilateral trinnnning of the feet and legs of the tip cartilages (Figure 10-2G). She now has a nnuch nnore natural shape to the colunnella. Note how much of an impact even a minor change in the droopiness of the columella makes in the overall shape of the nose. Figure 10-6C. Pre-op 3/4 view of hanging columella secondary to excess inferior caudal septal cartilage. This patient exhibits a significant columella deformity secondary to excess cartilage at the inferior caudal edge of the septum.This excess is pushing the soft tissues of the columella downward. Figure 10-6D. Post-op 3/4 view of reconstructed hanging columella deformity. This patient underwent a simple trimming of the inferior caudal edge of the septum (Figure I0-2G). Figure 10-6E. Pre-op lateral view of hanging columella secondary to excess inferior caudal septal cartilage. This patient exhibits a significant columella deformity secondary to excess cartilage at the inferior caudal edge of the septum.This excess is pushing the soft tissues of the columella downward. Figure 10-6F. Post-op lateral view of reconstructed hanging columella deformity. This patient underwent a simple trimming of the inferior caudal edge of the septum (Figure I0-2G).

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Figure 10-7. Reconstruction of Retracted Columella

Figure 10-7A. Pre-op lateral view of retracted columella. This patient exhibits a first-degree retracted columella deformity (Figure 10-3A). Figure 10-7B. Post-op lateral view of reconstructed retracted columella with cartilage plumping graft. This patient underwent a cartilage plumping graft reconstruction to correct the retraction in the columella (Figures I0-3B-C). Figure 10-7C. Pre-op 3/4 view of retracted columella. This patient exhibits a second-degree retracted columella deformity (Figure I0-3D). Figure 10-7D. Post-op 3/4 view of reconstructed retracted columella with auricular cartilage graft. This patient underwent an auricular cartilage graft reconstruction to correct the retraction in the columella (Figure I0-3E-F). Figure 10-7E. Pre-op lateral view of same patient. Figure 10-7F. Post-op lateral view of same patient.

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Figure 10-8. Reconstruction of Retracted Columella

Figure 10-8A. Pre-op lateral view of retracted columella. This patient exhibits a third-degree retracted columella deformity (Figure I0-3G). Figure I0-8B. Post-op lateral view of reconstructed retracted columella with composite auricular cartilage graft. This patient underwent a composite auricular cartilage graft reconstruction to correct the retraction in the columella (Figures I0-3H-I). Figure 10-8C. Pre-op 3/4 view of retracted columella. This patient exhibits a third-degree retracted columella deformity (Figure I0-3G). Figure 10-8D. Post-op 3/4 view of reconstructed retracted columella with auricular cartilage graft. This patient underwent a composite auricular cartilage graft reconstruction to correct the retraction in the columella (Figure I0-3H-I). Figure 10-8E. Pre-op lateral view of same patient. Figure 10-8F. Post-op lateral view of same patient.

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I N T E R N A L N A S A L VALVE R E C O N S T R U C T I O N

The success of cosmetic rhinoplasty is initially judged by aesthetics; however, the final result is deemed successful only if the internal nose functions well along with the external nose appearing attractive. Since the internal nasal valve is the most delicate anatomic area of the nose impacting the body, not only aesthetically but functionally, it behooves the rhinoplastic surgeon to become intimately familiar with this area so that surgical manipulation of the delicate tissues that comprise the nasal valve and its associated structures can be judiciously avoided if possible and exquisitely and exactingly manipulated when necessary.

SURGICAL ANATOMY The nasal valve is always cloaked in an aura of mysterious anatomical boundaries and delicate functionality. These factors imply that the best advice for the surgeon is to stay as far away as possible from the valve so as not to disturb its elusive functionality. This would be sound advice indeed if it weren't for the fact that the nasal valve literally sits in the middle of almost every rhinoplastic maneuver. The simplicity of the nasal valve anatomy belies its functionality and delicacy. The anatomic components and their interrelationships are easily understood; and as in all rhinoplastic surgery, if it is operated on in a judicious, elegant, and gentle manner, the outcome will usually be successful. The internal nasal valve, is by definition, the juncture of the anterior upper lateral cartilage and the nasal septum. The normal angulation between these structures is 10 to 15 degrees. Simply stated, the nasal valve is that part of the upper lateral cartilage that descends into the superior nasal vault. It is held in place medially along the junction of the upper lateral cartilage with the superior edge of the septum as a door would be hinged to a frame if the door were opening into the ground. This should not be confused with the "area" below the valve that is the total nasal vestibular opening unilaterally. This area is shaped like a teardrop, bounded medially by the septum; inferiorly by the floor of the nose and the soft tissues overlying the pyriform aperture; and laterally by the upper lateral cartilage and the lateral nasal wall including the turbinates. The apex of this structure is the nasal valve. The area that is encompassed by these tissue boundaries bilaterally, defines the total area through which air can flow through the nose. Although the tip cartilages are superficial to the valve and not involved directly with this flow relationship, the tip cartilage lends considerable, but often

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FUNCTIONAL ANATOMY AND PHYSIOLOGY The internal nasal valve is the primary regulator of nasal air flow and the narrowest part of the airway. Manipulation of its tissues must be limited and conservative, so as not to further inhibit this most delicate of regions. During inspiration, negative pressure is generated in the nasal respiratory tract, causing inward movement of the caudal aspect of the upper lateral cartilages that consequently narrow and close down the nasal valve. As the inspiratory effort increases, the negative pressure exerted on the tissues of the nasal vestibule increases, causing increased movement of the upper lateral cartilage into the nasal vestibule (medially toward the septum), effectively increasing the resistance to further airflow into the nose and lungs. During expiration these movements are reversed and the valve becomes wider as the upper lateral cartilage moves laterally away from the septum. The nasal musculature and the suspensory ligaments of the nasal SMAS exert fine-tuning control over the valve. The reason the valve exists only anteriorly is that the upper lateral cartilage is more firmly fixed to the nasal bones, and lateral tissues of the nose move cephalad and therefore cannot contribute to any significant movement. It is only the caudal border akin to a flag fixed rigidly at one edge, flapping in the breeze, that can modulate its position and act as a kinetic valve. It is just this kinetic flexibility that must be maintained during rhinoplasty, but that is usually compromised during flawed primary rhinoplastic procedures.

AESTHETICS Although the nasal valve is essentially an internal feature of the nose, destruction of the valve can significantly alter the external anatomy of the middorsal and supratip area. The aesthetic sequlae of valve destruction is usually a pinched narrowed area in the distal upper lateral cartilage region either alone or in combination with a tip deformity, that further worsens both the aethetics and functionality of this region.

FUNCTIONAL PATHOLOGY Any compromise of the cross-sectional area below the actual nasal valve will dramatically increase airway resistance, which will be interpreted and transformed into nasal congestive symptoms.

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Damage to the nasal valve can be categorized into etiologic categories based on 1. Anatomic malposition 2. Overaggressive tissue excision 3. Scar formation and secondary contracture Each of these can occur separately or compound each other by existing together. If, for example the upper lateral cartilage is too aggressively trimmed, then the valve will be compromised primarily by this malposistion and secondarily by scar formation due to an inability for the mucosal edges surrounding the upper lateral cartilages and the septum to reunite primarily. Tertiary compounding of the problem would exist if this scarring was overabundant and exuberant, and by its very bulk alone this would further compromise the nasal valve.

AESTHETIC PATHOLOGY The cosmetic sequelae of internal nasal valve stenosis is significant and deforming. Overzealous resection of the upper lateral cartilages will result not only in a scarred and incompetent nasal valve, but also in a disruption of the natural nasal contours in the middle third of the nose.

TECHNICAL CONCEPTS OF RECONSTRUCTION The integrity of the internal nasal valve must be preserved by using operative maneuvers that do not compromise either its structure or its function, thus preventing scar and secondary contracture and maintaining proper anatomic alignment by not interfering with cartilaginous support. This can be accomplished in two ways: 1. Complete avoidance of the nasal tissues that compromise the nasal valve 2. Judicious manipulations on the nasal valve components so that they heal well and function normally postoperatively The internal nasal valve is the centerpoint of two strategic incisions during routine rhinoplasty: the intercartilaginous incision and the disarticulation of the upper lateral cartilage from the septum. The slightest bit of damage and subsequent scarring in this area can cause devastating stenosis. It is, therefore, not surprising that many surgeons advocate complete avoidance of the nasal valve area during rhinoplasty. When possible, I support this thesis. If the rhinoplasty is limited to minimal change in proportion and size, then I advocate the use of intracartilaginous incisions to access the nasal dorsum, and refrain from disarticulating the upper lateral cartilages from the septum. These techniques will allow successful completion of the rhinoplasty and still leave the nasal valve untouched. I do, however, believe that when moderate or considerable alteration of nasal size, angulation, or rotation has occurred, it is naive to expect the nasal valve to

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Figure 11 -1A-B. Anatomy of nasal valve; 11 - 1 C - H . Etiology of internal nasal valve stenosis

Figure I l-l A.Anatomy of nasal valve. Note the attachment of the upper lateral cartilage just under the nasal bone causing the cephalic border of the upper lateral cartilage to be rigid, thus not able to function as a valve whereas the more pliable and kinetic caudal edge does so beautifully. In vivo diagram of nasal valve, readily apparent upon superior retraction of the tip cartilages. Figure 11 -1B. Anatomy of nasal valve. Diagrammatic representation of "total valve area" and normal angle of the actual internal nasal valve.The anatomic elements that define the total valve area are the septum medially the valve at the apex, the soft tissue and bone of the pyriform aperture, and the lobule and alar soft tissue laterally Suspensory ligaments of the tip cartilages contribute additional secondary support to the caudal edge of the upper lateral cartilages. Figure I l - I C . 1^ internal nasal valve stenosis. First-degree stenosis is due to blockage of internal nasal valve only Blunting is due to redundant mucosa, soft tissue scar tissue formation, or a combination.The main point, however; is that the valve still has full mobility and kinetic functionality and thus can still rotate medially and laterally with respiration; thus there is a minimal effect on the cross sectional area under the valve.This type of deformity is probably present to a variable degree in most postoperative rhinoplasties and causes little or no symptoms, although under careful intranasal physical exam, blunting of the valve will be evident Figure 11 -1D. 2^ internal nasal valve stenosis. Second-degree stenosis is due to scar contracture without significant bulk or blunting. Secondary stenosis significantly restricts the movement of the caudal edge of the upper lateral cartilage thereby closing down the valve permanently and decreasing the total crosssectional area under the valve considerably more than exists in a first-degree stenosis.This degree of stenosis is always symptomatic. Figure 11 -1E. 3^ internal nasal valve stenosis. Third-degree stenosis combines the characteristics of I and 2, thereby significantly affecting the total cross-sectional area under the nasal valve due to the combined effects of bulk and constricted movement. Figure 11 -1F. Internal nasal valve stenosis (collapse) secondary to loss of superior edge of upper lateral cartilage. Height of upper lateral cartilage is decreased due to overzealous excision at superior septal junction.The apex of the valve is filled with scar tissue.This not only inhibits airflow by a mechanical obstructive phenomenon but also inhibits the valve's ability to move freely thus decreasing valve function. Figure 11 -1G. Internal nasal valve stenosis (true collapse) secondary to subluxation of nasal bone into nasal vestibule combined with loss of superior edge of upper lateral cartilage. In this example the upper lateral cartilage is deficient at its superior edge but the entire complex collapses into the nasal vault due to collapse of the nasal bone medially Thus the initial deformity is exacerbated by the nasal bone dragging the attached upper lateral cartilage with it into the nasal vestibule. Figure 11 -1H. Combined internal nasal valve stenosis with view at level of nasal bone and at level of upper lateral cartilage. Upper: This view at the level of the nasal bones shows the bone subluxating into the nasal vestibule. LowerJhis view at the level of the upper lateral cartilage shows the nasal valve stenosis due to a loss of upper lateral cartilage worsened by the nasal bone collapse.

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Figure 11 -2. Reconstruction of internal nasal valve stenosis

Figure I I - 2 A . Internal nasal valve stenosis secondary to loss of valve mucosa with subsequent scar tissue formation. This stenosis is due totally to loss of mucosa and subsequent scar formation.The cartilaginous connponents of the nasal valve are intactThe scar and destroyed nnucosa are excised en bloc. Figure 11-2B. Reconstruction of internal nasal valve stenosis with split thickness skin graft. A split thickness skin graft is taken fronn the upper eyelid or preauricular region and trinnmed accordingly The graft is oversized to acconnmodate shrinkage during the healing process. Figure 11-2C. Corrected result. Graft is placed into the defect and sutured into place. A sponge packing innpregnated with antibiotic ointment is used to secure the reconstruction. Figure 11-2D. Internal nasal valve stenosis secondary to loss of superior edge of upper lateral cartilage. This stenosis is due to a loss of the superior edge of the upper lateral cartilage with an intact nnucosal lining and very little if any scar tissue formation. Figure 11-2E. Reconstruction of nasal valve stenosis with septal cartilage graft. A septal cartilage graft is harvested and appropriately trimmed. Figure 11-2F. Corrected result. The nasal valve is corrected after placement of septal cartilage graft into position. Alternatively any cartilaginous graft material may be used. Figure I I - 2 G . Internal Nasal Valve Stenosis Secondary to Loss of Superior Edge of Upper Lateral Cartilage and Loss of Mucosa with Scar Tissue Formation. This stenosis is due to a loss of the superior edge of the upper lateral cartilage associated with mucosal loss and subsequent scar tissue formation. It is the most devastating both physiologically and cosmetically Figure 11-2H. Reconstruction of nasal valve stenosis with conchal composite graft. A conchal graft is harvested from the auricle.The graft site is either closed primarily or is skingrafted with postauricular skin.The graft is designed to the appropriate size to fill the defect, with a margin of skin larger than the area of cartilage.The septum is notched to lend stability to the graft placement. Figure 11-21. Corrected Result. The graft is placed into the notched septum and the mucosa is sutured to the skin portion of the composite graft. Nasal packing is placed for one week (see Figure I I -2C).

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Figure 11-3. Reconstruction Of Internal Nasal Valve Stenosis

Figure I I - 3 A . Pre-op 3/4 view of external deformity secondary to internal nasal valve stenosis. This patient exhibits an external concave deformity of the supra-tip region secondary to internal nasal valve stenosis. Figure I I - 3 B . Post-op 3/4 view of reconstructed internal nasal valve. This patient underwent a septal cartilage graft reconstruction for internal nasal valve stenosis (Figures I I-2D-F). Figure I I - 3 C . Pre-op lateral view of same patient. Figure 11-3D. Post-op lateral view of same patient. Figure I I - 3 E . Pre-op 3/4 view of external deformity secondary to internal nasal valve stenosis. This patient exhibits an external concave deformity of the supra-tip region secondary to internal nasal valve stenosis. Figure 11-3F. Post-op 3/4 view of reconstructed internal nasal valve. This patient underwent a septal cartilage graft reconstruction for internal nasal valve stenosis and a tip plasty (Figure I I -2 D-F)

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•11 NASAL ROTATION

Nasal rotation is another key category into which many revisional deformities reside. The classic "piggy" nose is in actuality an extremely upwardly rotated nose, associated with tip deformities. The other end of the rotational spectrum is the droopy downward-tilting deformity. Rotational deformities are rarely isolated, and are usually associated with other classic problems that can be defined as an aesthetic pathologic syndrome. These syndromes or, more accurately, collections of deformities, do not haphazardly occur. They are a direct result of a preexistent genetic propensity, associated with over- or underresection of several key areas of tissue. Syndrome 1 (see Figure 12-1) which might be labeled the "piggy nose" is a severely upwardly rotated nose and a low bony dorsum. The full-blown syndrome would include a pointy unnatural tip deformity. In this case too much dorsal hump was removed; there is over-resection of the caudal end of the Upper Lateral Cartilages; underresection of the cartilaginous dorsum and caudal end of the septum; and overresection of the cephalic borders of the tip cartilages. This full-blown syndrome may exist in part or in totality in any given patient. The opposite syndrome, which is far easier to correct, because it's etiology is based on lack of excision instead of too much removal of tissue, is that of a severely downwardly rotated nose which is best described as a droopy, tipped down, bulbous nose. In the full-blown syndrome there is an excess bony dorsum as well as a bulbous tip and usually a retracted columella, which contributes to the downward tilt of the nose. For the surgeon to more accurately appreciate the concepts of downwardly rotated nasal deformities, delineation of the components of this problem, starting superiorly and working inferiorly, can be identified as: 1. 2. 3. 4. 5. 6. 7.

Excessive bony hump (note: generally only the caudal inferior portion of the nasal bones are excessive). Excessive upper lateral cartilages. Large bulky tip cartilages (elongated in a superio-inferior direction) weighs down the tip and also push down the tissues. Excessive (high) cephalic edge of dorsal cartilaginous septum. Recessive (low) caudal edge of dorsal cartilaginous septum. Short and recessive inferior-caudal edge of cartilaginous septum. Retracted columella base (including nasal spine).

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Retracted membranous columella. Bulbous, thick, and heavy skin.

The key to this reconstructive effort is judicious and accurate reconstruction of the above components or each of the components, which are operative in each particular patient. Reconstruction of these components will begin by visualizing and redefining a new line of rotation throughout all of the above-stated components. This will allow these elements to fit comfortably into one another in a smooth and natural integration of bone, cartilage, and soft-tissue. Fig. 12-4A-C

AREAS THAT D E F I N E NASAL ROTATION (MAJOR INFLUENCE) 1. Caudal septum—inferior edge. The caudal septum is a key area in defining and changing rotation of the lower half of the nose. Its inferior edge, which inserts into the nasal spine, can for practical purposes be considered an anatomical extension of the actual inferior caudal septum, even though the septum is cartilaginous and the spine is bony. This inferior extent of the caudal septum plays an immensely important role in defining the proper nasal rotation and consequently, in reversing some of the rotational deformities. 2. Caudal septum—superior edge (transistion zone with dorsal septum). The uppermost area of the caudal septum, which flows into the dorsal septal area also, defines rotation. It does so most directly at the superior septal angle and also indirectly because of its support of the tip cartilages. This area is the anatomic determinant of the aesthetic concept of a "double break," which is considered an important aesthetic complex and part of the traditionally beautiful nose. 3. Upper lateral cartilage (caudal edge). The caudal edge of the upper lateral cartilage is an extremely important anatomical point of reference not only because of its intimate relationship with the delicate physiology of the nasal valve but also because of the key aesthetic influence it plays in rotational changes of the nose. The interrelationship of this area with the cephalic edge of the tip cartilages allows for significant control over the rotation of the nose (See Figure 12-1). The key concept is that there is an area of soft tissue between the upper lateral cartilage and the tip cartilages that have the potential to contract if one or both of these cartilaginous structures are trimmed. This contraction can be used to a reconstructive advantage when upwardly rotating a downward tilted nose. It can also contribute to a deformity if both areas are excessively trimmed. The correction of this type of extreme upward rotation must include freeing up the scarred area and replacing the loss of mucosal and cartilaginous tissues (Figure 12-lG-I).

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AREAS T H A T D E F I N E NASAL ROTATION (MINOR INFLUENCE) Tip cartilages. The tip cartilages are seen as a minor influence on total nasal rotation in part due to their relationship with the upper lateral cartilage. I classijfy the tip cartilages as being of minor influence because their manipulation alone will not significantly affect nasal rotation. It is only when coupled with an alteration of the upper lateral cartilage can significant nasal rotation occur. Of course tip rotation or, more correctly, pseudotip rotation can be directly determined by alteration of tip cartilges alone. The definition of pseudorotation in this context of nasal aesthetics is actually not a true rotation but an optical illusion that occurs when an actual change of one anatomical section of the nose influences another. In connection with rotation, for example, the actual alteration occurs in the cephalic borders of the tip cartilages that changes the appearance of the nasal tip. This maneuver will in fact make the tip more refined and impart to the supra-tip area a slight aesthetically pleasing and desirable depression. This refinement will have several beneficial effects on the total aesthetics of the nose, among them a more refined nasal tip. Of secondary improvement will be an apparent or pseudo—^upward rotation of the nose, because the eye is fooled into believing that the tip is actually rotated upwards. This tip refinement coupled with the supra-tip depression imparts an optical illusion of upward nasal rotation. Bony dorsum. The upper one-third of the nose also exerts a minor influence on total nasal rotation in that a scooped-out nose from overexcision of bony dorsum gives the impression of an upturned nose, while a toohigh dorsum sets up a line-of-sight optical illusion whereby the eye begins to follow a downward cascading line starting at the root of the nose, which imparts a pseudo droop to the nose. These forces, however, do not actually physically rotate the nose but contribute to that illusion.

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Figure 12-1. Basic reconstruction of upwardly rotated nasal deformities (1^2^ 3^): basic techniques to adjust downward

Figure 12-1 A. First-degree deformity. First-degree deformity of upward rotation is defined as slightly more upward than desirable. The exact angle differs depending on sexThe aesthetic pathology presents as a normal bony dorsum, a heightened dorsal cartilaginous hump, and redundant inferior-caudal cartilaginous septum and spine.This excess cartilaginous structure upwardly rotates the nose by pushing the soft-tissue envelope outward and upward. Figure 12-1B. Soft-tissue slide reconstruction. Reconstruction is performed by first releasing and then sliding the soft-tissue envelope downward and inward, thus redefining the nasolabial angle.This is accomplished by excision of the redundant dorsal (I) and caudal (2) quadrangular cartilage of the septum.The bony vault is not involved, so that typically the excision of excess cartilage is initiated just below the bony dorsum and continues down and around the bottom of the nose.This redefinition of the angle easily corrects a primary upward rotational defect. Figure 12-1C. Corrected result. After release of the soft-tissue envelope, the tissues slide into place, recreating a normal rotational angle. One or two tacking stitches of 4-0 chromic placed from the septum to the soft-tissue envelope helps secure the reconstruction. Figure 12-1D. Second-degree deformity. Second-degree deformity of upward rotation is defined as moderately more upward than desirable.The aesthetic pathology presents as a lowered bony dorsum due to genetic predisposition or overzealous excision of the dorsal nasal bone, as well as excess quadrangular cartilage, as described under primary deformity above. Figure 12-1E. Soft tissue slide reconstruction coupled with dorsal augment. The correction of this deformity combines the corrective maneuvers utilized for a first-degree deformity with the addition of a dorsal augmentation graft of choice. Figure 12-1F. Corrected result. The dorsal augmentation graft should override the cartilaginous dorsum to effect a smooth transition. Figure 12-1 G.Third-degree deformity. Third-degree deformity of upward rotation is defined as an extremely upwardly rotated nose. The aesthetic pathology presents as a true loss of upper lateral cartilage (caudal edge) added to the previous deformity (second degree), thereby compounding the rotational, problem. This degree of deformity can also occur by overresection of the cephalic borders of the tip cartilages, either alone or in combination with excessive caudal upper lateral cartilage resection. The technical correction of this most severe upward rotation of the nose combines the previous two maneuvers with an auricular graft taken from the cavum concha and partially split and placed in the scarred bed of the upper lateral cartilage area.This elongation of the midsection of the nose, combined with dorsal augmentation and septal cartilage manipulation, will correct this most severe deformity Figure 12-1H. Harvesting full-thickness composite auricular graft. Reconstruction is begun by harvesting a full-thickness composite graft from the cavum concha and closing the donor defect primarily Figure 12-11. Preparation of composite graft. Upper lateral cartilage defect is measured and graft is appropriately trimmed. One-half of the graft is split and filleted with a scalpel through the midportion of the cartilage, thus opening up the top half of the graft so that equal parts of skin and cartilage reside on each of the open leaves of the newly shaped graft.

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Figure 12-2. Basic reconstruction of upwardly rotated nasal deformities (1^2° 3*^): basic techniques to adjust downward

Figure 12-2A. Preparation of graft site. Preparation of the graft site begins with an intercartilaginous incision. Figure I2-2B. Further preparation of graft site. Transfixtion incision continues the exposure to the scarred upper lateral cartilage area. Figure 12-2C. Delineation of graft site. The scalpel is placed through the intercartilaginous incision and used to undernnine and release the scarred area. Figure 12-2D. Continued delineation of graft site. Scissors are used to excise scar tissue and freshen the donor bed. Figure 12-2E. Graft site open. Graft site is now open and prepared to accept graft. Figure f 2-2F. Preparation of auricular graft. The technical correction of this nnost severe upward rotation of the nose is perfornned with an auricular graft-This elongation of the midsection of the nose may be combined with dorsal augmentation and septal cartilage manipulation as needed. Figure 12-2G. Corrected result. The prepared graft is placed into the defect and sewn into place.The third-degree upward rotation deformity may exist with or without a bony dorsal problem and exist solely as a result of overresection of the upper lateral cartilages combined with overresection of the tip cartilages. A proper diagnosis must be made to match the deformity with the reconstructive efforts.The above figures will allow one to correct almost any upwardly rotated deformity but the surgeon must choose the correct combination of techniques to complete the reconstruction.

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Figure 12-3. Adjunctive techniques to adjust downwards The basic techniques described above are not always adequate to control the degree of downrotation that is necessary to effect the appropriate repair Additional techniques are described below. Figure 12-3A. Extended soft-tissue slide reconstruction. If the soft-tissue slide reconstruction described above is not adequate to effect the desired result, it may nnean that the soft tissues need to slide nnore inferio-posteriorly thus further downwardly rotating the nose. Excision of the nasal spine in continuity with the inferior edge of the nasal septum (quadrangular cartilage + premaxillary crest) allows for additional room for this rotation to occur Figure I2-3B. Extended soft-tissue reconstruction with sutures. If the extended soft-tissue reconstruction is not adequate or if more control over the tissues is desirable, then actual sutures are used to secure the membranous columella downward and inward into the newly formed caudal septum.This technique is very powerful and can effect a considerable adjustment to the tissues without any external scarring. Figure 12-3C. Columella wedge resection for extended downward rotation. This technique addresses the fact that in certain overly upwardly rotated noses, the columella itself is an important component of the problem. Often the tissue is rather dense and has a strong influence on supporting and rotating the tip of the nose in an upward rotation. If more downward adjustment is necessary and the primary barrier to this reconstruction is too much length and strength of the membranous columella, then wedge resection of the mid to low portion of the columella is outlined. Figure 12-3D. Suture repair of columella wedge resection. Sutures of 6-0 nylon are used to secure the reconstruction. Figure 12-3E. Columella full-thickness resection. If technique 12-3C-D is not enough to effect the desired rotation, then an entire section of membranous columella has to be removed.This allows for substantial shortening and downward rotation of the columella, although an external scar will be obvious. Figure 12-3F. Suture repair of full-thickness resection. Sutures of 6-0 nylon externally and one suture of 4-0 Mersilene subcutaneously are used to secure the reconstruction.

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Figure 12-4. Reconstruction of downwardly rotated nasal deformities: basic techniques to adjust upward

Figure 12-4A. Figure of cartilaginous and bony components contributing to downward rotation (external view). Excessive bony hump (caudal portion) (I), excessive upper lateral cartilages (2), and heavy elongated droopy tip cartilages (3) are the external components causing a downward rotation of the nose. Figure 12-4B. Figure of cartilaginous and bony components contributing to downward rotation (internal view). Excessive (high) cephalic edge of dorsal septum ato b (4) combined with recessive (low) caudal edge of dorsal septum b to c (5), short and recessive inferior-caudal edge of cartilaginous septum (6), retracted columella base (7) are the internal components causing a downward rotation of the nose. Figure 12-4C. Figure of soft-tissue components contributing to downward rotation. Bulbous, thick, and heavy skin (8) and retracted membranous columella (9) are the major soft-tissue components causing a downwardly rotated nose. Figure 12-4D. Excision of excessive cephalic edge of dorsal septum to facilitate upward rotation. The primary step in readjustment of the nose upward is to undrape and expose the septum, upper lateral cartilages, and nasal bones.The upper lateral cartilages are sharply separated from the septum.The scalpel is then reintroduced into the nose and angled to set up the new rotational line of sightThe two things to consider with this very important first step is (I) the amount of dorsal cartilaginous septum which will be removed and (2) the angle at which it should be removed.This angle will also define the amount of upper lateral cartilage and bony dorsum that will ultimately be removed in the same procedure. Removing the cartilaginous septum, the bony dorsum, and the upper lateral cartilages en bloc simplifies the planning and also minimizes trauma to the tissues, allowing for more accuracy in removal and readjustment of these critically important tissues. Figure 12-4E. Excision of excess bony hump to facilitate upward rotation. A chisel is then reinserted into the previously cut dorsal septum and the excision is continued into the bony dorsum. Chisels of decreasing widths are used as one progresses superiorly so as not to damage the external skin. Figure 12-4F. Excision of excess upper lateral cartilages to facilitate upward rotation. Upper lateral cartilages are visualized and trimmed to the appropriate height already predetermined by the height of the dorsal septum. (See Figures in the chapter on the upper lateral cartilage area for a more accurate picture of this maneuver).The tissue components of bony dorsum connected to both the dorsal septum and upper lateral cartilages are removed en bloc. Figure 12-4G. Manipulation of cephalic-tip cartilages and caudal upper lateral cartilage. Upper, excision of excessive cephalic edge of tip cartilages and caudal edge of upper lateral cartilages are used to facilitate upward rotation.The elongated bulky tip cartilages associated with droopy caudal edges of the upper lateral cartilages are trimmed to facilitate upward rotation. Lower.The appropriate excision of caudal edge of upper lateral cartilage is performed with a right-angled scissors. Care is taken not to overexcise, which could cause internal nasal valve contractures and stenosis. Figure I2-4H. Excision of excessive cephalic edge of tip cartilages and caudal edge of upper lateral cartilages to facilitate upward rotation via formation of scar contracture. UpperJhe excision of the cephalic edge of tip cartilages combined with the caudal edge of the upper lateral cartilage completes the maneuvers necessary to upwardly rotate the nose. LowerJhese last two maneuvers will set up a scar formation between the upper lateral cartilages and the tip cartilages that will tend to upwardly rotate the lower third of the nose. Internal cross-hatching of the nasal skin in this area will also help to soften the skin and allow it to more readily confirm to the new nasal shape.

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Figure 12-5. Reconstruction of downwardly rotated nasal deformities: adjunctive techniques to adjust upward If after performing the basic techniques outlined in Figure 3, more upward rotation is desired, then the techniques depicted below can be used. Figure 12-5A. Downwardly Rotated Nose Due to Severe Columella Retraction. Severe retraction of the columella and base of the nose can contribute significantly to downward rotation. Figure I2-5B. Reconstruction of downwardly rotated nose due to severe columella retraction by plumping graft. Plumping grafts placed anterior to the nasal spine through a small incision in the membranous columella can physically lift and rotate the columella, effecting upward rotation to the base of the nose. Figure 12-5C. Downwardly rotated nose due to droopy-tip cartilages. Droopy-tip cartilages can cause significant downward rotation of the entire lower third of the nose. Figure I2-5D. Reconstruction of downwardly rotated nose due to droopy-tip cartilages by columella lengthening and tip support graft. Placing a columella and tip support graft into a pocket within the membranous columella effects this reconstruction.This lengthening graft actually rotates the nose upward by physically lifting up the tip cartilages and pushing up the membranous columella. Figure 12-5E. Downwardly rotated nose due to a combination of retracted columella and droopy-tip cartilages. A combination of these two deformities acts synergistically to compound the downwardly rotated nose. Figure 12-5F. Reconstruction of downwardly rotated nose due to droopy tip cartilages by a combination columella plumping and lengthening and tip support graft. Preparation of graft site. Graft site is prepared by tunneling between the tip cartilages through an incision in the membranous columella. Graft is then placed into the tunnel and actually lifts up and rotates tip cartilages, while at the same time lengthening the distance between the nasal spine and the feet of the tip cartilages. In addition, the plumping part of the graft corrects the retraction in the columella. Figure 12-5G. Corrected result of combined graft. A lateral view of the corrected result illustrates the combined graft in place.This graft ideally will (I) lenghthen the distance of the caudal end of the septum, (2) plump up the base of the columella, and (3) thicken and correct the retraction in the membranous columella.

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Figure 12-6.Titanlum reconstruction of downwardly rotated nasal deformities If the nasal tip is bulbous, heavy, and droopy, and it is associated with retraction of the colunnella, a nnore substantial reconstructive effort is needed to actually lift these tissues superiorly This figure examines a titanium reconstruction that is easy to perform and dependable. Figure 12-6A. Bulbous, hanging, droopy-tip associated with columella retraction. This type of tip needs a strong reconstructive effort to lift the tissues superiorly Figure 12-6B. Midline gingival incision. The reconstruction is initiated with a midline gingival incision directly into the frenulum down to bone. Figure 12-6C. Exposure of nasal spine. The incision is carried superiorly to expose the nasal spine. Figure 12-6D. Dissection into membranous columella. A Stevens scissors continues the dissection into the membranous columella. Figure 12-6E. Dissection below tip cartilages. A right-angled scissors continues the dissection into the tip area, below the tip cartilages. Figure 12-6F. Measurement of implant. After the dissection is complete, the area from just below the nasal spine into the flattened portion of the subspine bone is measured superiorly to the tip. Figure 12-6G. Construction of titanium implant. The titanium is measured to the appropriate length and bent into the shape illustrated. Figure 12-6H. Placement of titanium implant. The designed implant is screwed into place with a self-drilling screwThe incision is closed with 5-0 chromic. Figure 12-61. Corrected result. The lateral view shows the completed reconstruction. Hand manipulation of the titanium after placement and closure will ensure the proper angle of rotation. Note that the implant sits below the tip cartilages.

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Figure 12-7. Reconstruction of first-degree upwardly rotated nasal deformity

Figure 12-7A. Pre-op side view of first-degree upwardly rotated nasal deformity. This patient exhibits first-degree upward rotation (Figure 12-1 A). Figure 12-7B. Post-op side view of corrected revisional result. This patient underwent trimnning of the dorsal and caudal quandrangular cartilage of the septum (Figure 12-1B-C). Figure I2-7C. Pre-op side view of first-degree upwardly rotated nasal deformity. This patient exhibits first-degree upward rotation (Figure 12-1 A). Figure 12-7D. Post-op side view of corrected revisional result. This patient undenA/ent trinnnning of the dorsal and caudal quandrangular cartilage of the septunn (Figure 12-1 B-C). Figure 12-7E. Pre-op side view of first-degree upwardly rotated nasal deformity. This patient exhibits first-degree upward rotation (Figure 12-1 A). Figure 12-7F. Post-op side view of corrected revisional result. This patient underwent trimming of the dorsal and caudal quandrangular cartilage of the septum (Figure 12-1B and C).

Figure 12-7A

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Figure 12-8. Reconstruction of second-degree upwardly rotated nasal deformity

Figure 12-8A. Pre-op frontal view of second degree upwardly rotated nasal deformity. This patient exhibits a second-degree upward rotation (Figure 12-1D). Figure I2-8B. Post-op frontal view of corrected revisional result. This patient underwent trinnnning of the dorsal and caudal quadrangular cartilage of the septunn in addition to a dorsal augnnentation procedure (Figure 12-1E-F). Figure 12-8C. Pre-op side view of same patient. Figure 12-8D. Post-op side view of same patient. Figure 12-8E. Pre-op 3/4 view of same patient. Figure 12-8F. Post-op 3/4 view of same patient.

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Figure 12-9. Reconstruction of third-degree upwardly rotated nasal deformity

Figure I2-9A. Pre-op frontal view of third degree upwardly rotated nasal deformity. This patient exhibits a third degree upward rotation (Figure 12-1G). Figure I2-9B. Post-op frontal view of corrected revisional result. This patient under^vent the nasal reconstructive procedures outlined in Figures 12-1 H-l and I2-2A-G. Figure 12-9C. Pre-op side view of same patient. Figure 12-9D. Post-op side view of same patient. Figure 12-9E. Pre-op 3/4 view of same patient. Figure 12-9F. Post-op 3/4 view of same patient.

Figure 12-9A

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Figure 12-10. Adjunctive techniques to adjust downward

Figure 12-1OA. Pre-op side view of upwardly rotated nasal deformity. This patient exhibits significant upward rotation (Figure 12-3A). Figure 12-1 OB. Post-op side view of corrected revisional result. This patient undePvvent the procedures in Figure 12-3A-B. Figure 12-1OC. Pre-op side view of upwardly rotated nasal deformity. This patient exhibits significant upward rotation. Figure 12-1OD. Post-op side view of corrected revisional result. This patient underwent the procedures in Figure 12-3 C-D. Figure 12-1OE. Pre-op side view of upwardly rotated nasal deformity. This patient exhibits significant upward rotation. Figure 12-1 OF. Post-op side view of corrected revisional result. This patient underwent the procedures in Figures I2-3E-F

Figure 12-10A

Figure 12-10 B

Figure 12-10 C

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Figure 12-11. Reconstruction of downwardly rotated nasal deformity (basic technique to adjust upward)

Figure 12-11 A. Pre-op side view of downwardly rotated nasal deformity. This patient exhibits significant downward rotation (Figures 12-4A-C). Figure 12-11B. Post-op side view of corrected revisional result. This patient underwent the procedures in Figures 12-4D-H. Figure 12-11C. Pre-op side view of downwardly rotated nasal deformity. This patient exhibits significant downward rotation (Figures 12-4A-C). Figure 12-11D. Post-op side view of corrected revisional result. This patient underwent the procedures in Figures I2-4D-H. Figure 12-11E. Pre-op side view of downwardly rotated nasal deformity. This patient exhibits significant downward rotation (Figure 12-4A-C). Figure 12-11F. Post-op Side view of corrected revisional result. This patient underwent the procedures in Figures 12-4D-H.

Figure 12-11A

Figure 12-11B

Figure 12-11C

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Figure 12-12. Reconstruction of downwardly rotated nasal deformity (adjunctive techniques to adjust upward)

Figure 12-12A. Pre-op side view of downwardly rotated nasal deformity. This patient exhibits significant downward rotation (Figure 12-5A). Figure I2-I2B. Post-op side view of corrected revisional result. This patient underwent the procedures in Figure I2-5B. Figure 12-12C. Pre-op 3/4 view of same patient. Figure 12-12D. Post-op 3/4 view of same patient. Figure 12-12E. Pre-op 3/4 view of downwardly rotated nasal deformity. This patient exhibits significant downward rotation (Figure 12-5C). Figure 12-12F. Post-op side view of corrected revisional result. This patient underwent the procedures in Figures 12-5C-D.

Figure 12-12A

Figure 12-12B

Figure 12-12C

Figure 12-12D

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Figure 12-13 A - B . Reconstruction of downwardly rotated nasal deformity (adjunctive techniques to adjust upward); 12-13C-R Titanium reconstruction of downwardly rotated nasal deformity

Figure 12-13A. Pre-op side view of downwardly rotated nasal deformity. This patient exhibits significant downward rotation (Figure 12-5E). Figure 12-13B. Post-op side view of corrected revisional result. This patient underwent the procedures in Figures I2-5F-G. Figure 12-13C. Pre-op side view of downwardly rotated nasal deformity. This patient exhibits significant downward rotation (Figure 12-6A). Figure 12-13D. Post-op side view of corrected revisional result. This patient undenA/ent the procedures in Figures 12-6B-J. Figure I2-I3E. Pre-op 3/4 view of downwardly rotated nasal deformity. This patient exhibits significant downward rotation (Figure 12-6A). Figure 12-13F. Post-op side view of corrected revisional result. This patient underwent the procedures in Figures 12-6B-J.

Figure 12-13A

Figure 12-13B

Figure 12-13C

Figure 12-13D

Figure 12-13E

Figure 12-13F

filfflll ulllll ILII lu

TRANSITION Z O N E S

SURGICAL ANATOMY Zone 1. Between the inferior edge of nasal bony dorsum and the superior edge of the cartilaginous midnasal vault. This zone defines the transition area of the upper middle third of the nasal dorsum. It is composed of very unusual and highly reactive nasal tissue that is part bone and part cartilaginous with the intervening connective tissue bridging these two distinct tissue entities. It is this very reactive connective tissue that gives rise to multiple revisional problems. Zone 2. Between the tip cartilages and the supra-tip region. This zone defines the transition area of the lower middle section of the nose. It is composed of the cephalic borders of the tip cartilages that drop off superiorly to the upper lateral cartilage that lies below the plane of these cartilages. There is soft tissue and connective tissue that envelops this area causing a smooth transition. The dorsal edge of the quadrangular cartilage of the septum defines the height of this zone. Zone 3- Between the tip and columella. This zone defines the transition area at the base of the nose. It is composed of the legs and feet of the tip cartilages. The caudal edge of the quadrangular cartilage also influences this area as a foundation for the tip cartilages to rest upon. Some of the support is also due to the membranous columella.

AESTHETICS Zone 1. In men the transition zone may have a slight convexity to it that serves to delineate the inferior edge of the nasal bones. Usually in women this zone should be perfectly straight and smooth with just a hint of definition to demarcate the transition. Zone 2. This zone should appear as a smooth transition between the higher tip cartilages and the lower upper lateral cartilages. The cartilaginous dorsal edge of the septum should not be higher then the upper lateral cartilage.

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AESTHETIC PATHOLOGY Zone 1. When this area is manipulated by either sharp dissection with scissors or chisel, but especially by ragged dissection with a rasp or file, the connective tissue components react by densely proliferating and causing dorsal contour irregularities. Zone 2. Contour irregularities in this zone are directly related to trimming of the tip cartilages in an asymmetric or ragged way. Macerating or trimming the upper lateral cartilages in such a manner also causes scar tissue collapse of these structures. If the dorsal border of the quadrangular cartilage is too high, the nose exhibits a polybeak or pseudo-polybeak deformity. If the septum is too low, the tip cartilages stick up too high for the upper lateral cartilage area, giving the appearance of an upwardly rotated and piggy nose. Zone 3- Irregularities in the feet and legs of the tip cartilages or in the superior edge of the caudal septum will exhibit multiple irregularities in angle and contour.

TECHNICAL CONCEPTS OF RECONSTRUCTION Zone 1. Dorsal irregularities in this zone are notoriously difficult to repair, due to the vigorous responsiveness of the connective tissue in this area. This not only causes a proliferation of connective tissue but components of neocartilaginous and neoosteogenic tissue. Simple rasping of this area is generally not useful, and a complete exposure to the various components of the zone is usually indicated. At this point sharp medial dissection and separation of the nasal bones cleanly up to the frontal bone is performed. All areas in the midline that protrude are dissected cleanly and sharply with a chisel. Next, any bone that protrudes dorsally is carefully chiseled and gently rasped to the proper height. Finally, a serrated and strong dorsal scissors completes the excision of the upper lateral cartilage, to match the height previously determined by the nasal bones. Zone 2. This zone must be reconstructed to match the correct diagnosis. If there is a height differential between the upper lateral cartilage and the tip, due to the quadrangular cartilage, then this must be corrected. If the cephalic borders of the tip cartilages are to blame for the contour defect, then appropriate measures directed solely at the tip cartilages will suffice. If the upper lateral cartilages are collapsed or deficient or scarred, then reconstruction of this area will be in order. Any combination of these etiologies may be operative and any or all of them may have to be addressed.

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Zone 3. Diagnosis of the pertinent anatomic etiology is a must to recreate a pleasing double break in this area. The quadrangular cartilage must be appropriately trimmed and sculpted to give just the correct angle of support for the tip cartilages to remain at the correct angle. Manipulations of the membranous columella as well as the feet and legs of the tip cartilages will also be necessary to correct certain problems illustrated below.

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Figure 13-L Reconstruction of Transition Zone I Deformities Since contour defornnities in transition zone I are so difficult to reconstruct, due to the nature of the tissues involved, a technique of sequential reconstruction has been outlined in subsequent figures.This technique affords the advantage of cleanly rennoving all the offending tissues and bringing the area back to a nornnal contour Figure 13-IA.Transition zone I. This zone includes the area encompassing the inferior portion of the nasal bones and the superior part of the upper lateral cartilages. It also includes the highly reactive nasal tissue that connects the upper lateral cartilages to the undersurface of the nasal bones. Figure 13-1B. Convex deformity in transition zone I . Upper: An irregular growth of tissue ennanating fronn the connective tissues bridging the bone and cartilage in transition zone I can have a soft or hard consistency It usually contains elements of new cartilage or bone growth, or a combination of the two. Lower: Lateral view. Figure 13-1C. Separation of upper lateral cartilage from the septum. The upper lateral cartilage is separated from the septum sharply with a scalpel. Figure 13-1D. Medial osteotomies and out-fracture of nasal bones. Upper:\Ae6\d\ osteotomy is performed to disarticulate the nasal bones from each other and from the septum. Lower: Out-fractures bilaterally help to isolate the midline septum and the tissue deformity emanating from the nasal bones, the upper lateral cartilages, and their connecting tissue. Figure 13-IE. Serrated scissors incision of upper lateral cartilage. The scissors is used to gain control of the deformity from below.The scissors incises the normal upper lateral cartilage and continues superiorly Figure 13-1F. Chisel excision of bony portion of the deformity. The chisel continues in the same incision line as in Figure 13-1E and comes through the bone excising the deformity Figure 13-1G. Medialization of nasal bones. The nasal bones are medialized by digital compression. Figure 13-1H. Rasp reconstructed area. Judicious rasping with a fine diamond cross-hatched file finishes and smooths the area. A regular rasp that disrupts and pulls on this delicate tissue too much should be avoided. Figure 13-11. Fine-tuning contour irregularity. If the reconstructed area remains roughened, then "Gelfoam" padding can be used to soften the area. Optionally tissue clay or fascia can be used.

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Figure 13-2. Reconstruction of Transition Zone 2 and 3 Deformities

Figure 13-2A.Transition zone 2. Transition zone 2 is defined by the confluence of three separate anatonnic connponents: (I) the cephalic border of the tip cartilage; (2) the dorsal border of the upper lateral cartilage; (3) the dorsal border of the quadrangular cartilage. Figure l3-2B.Zone 2 deformity secondary to heightened dorsal border of the quadrangular cartilage. If the dorsal border of the quadrangular cartilage is too high, it disrupts the ideal slope in this zone by lifting the tip cartilages and the upper lateral cartilages too high.This artificially rotates the nose upward.Trimming of the'dorsal border of the septum is indicated to correct this problem. Figure l3-2C.Zone 2 deformity secondary to heightened dorsal border of the upper lateral cartilage. If the upper lateral cartilage is too high, then the normal transition between normally higher placed tip cartilages and the lower situated upper lateral cartilage is blunted. Judicious trimming to adjust this height discrepancy is indicated. Figure 13-2D.Transition zone 3. Transition zone 3 is defined by the confluence of three separate anatomic components: (I) the legs and feet of tip cartilages; (2) the caudal border of the septum; (3) membranous columella Figure 13-2E. Zone 3 deformity secondary to increased projection of caudal septum. If the caudal septum is excessively projected, it influences the lower portion of the tip cartilages and also pushes out the membranous columella. Figure 13-2F. Reconstruction of excessive zone 3 projection. Reconstruction of excessive projection in zone 3 is best handled by excisional sculpting of caudal septum to obtain the correct angulation and projection. Exposure to the caudal septum is via an extended transfixtion incision. Figure 13-2G. Zone 3 deformity secondary to excessive or aberrantly placed foot of tip cartilage. Excessive or aberrant foot of the tip cartilage causes significant deformity of the membranous columella. Simple excision of the offending foot will routinely solve the problem. Figure I3-2H. Excision of foot of tip cartilage. Excision of foot of the tip cartilage is performed as illustrated. Figure 13-21. Placement readjustment of membranous columella by trimming of interior skin. Trimming of interior membranous columella skin is used to readjust the position after reconstruction of foot of the tip excision or as an individual procedure.

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Figure 13-3 A - D . Reconstruction of Transition Zone I Deformity; 13-3 E-R Reconstruction of Transition Zone 2 Deformity

Figure 13-3A. Pre-op 3/4 view of patient with transition zone I deformity. This patient exhibits a convex deformity of the area incorporating the inferior portion of the nasal bones and the superior portion of the upper lateral cartilages (Figure 13-1B). Figure 13-3B. Post-op 3/4 view of reconstructed result. This patient underwent a reconstruction of transition zone I defornnity outlined in Figures 13-IC-H. Figure 13-3C. Pre-op Frontal view of same patient. Figure 13-3 D. Post-op frontal view of same patient. Figure 13-3E. Pre-op side view of patient with transition zone 2 deformity. This patient exhibits an excessively high dorsal border of the quadrangular cartilage, lifting both the tip and upper lateral cartilages (Figure 13-2B). Figure 13-3F. Post-op side view of reconstructed result. This patient underwent a reconstruction of transition zone 2 deformity The judicious trimming of the excess dorsal quadrangular cartilage allowed the tip and upper lateral cartilages to assume a more normal position, thus decreasing the upward rotation and slightly decreasing the projection.

Figure 13-3A

Figure 13-3B

Figure 13-3C

Figure 13-3D

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Figure 13-4. Reconstruction of Transition Zone 2 Deformity

Figure 13-4A. Pre-op side view of patient with transition zone 2 deformity. This patient exhibits an excessively high dorsal border of the quadrangular cartilage, lifting both the tip and upper lateral cartilages (Figure 13-2B). Figure 13-4B. Post-op side view of reconstructed result. This patient unden/vent a reconstruction of transition zone 2 defornnity outlined in Figure 13-2C.The judicious trinnnning of the excess dorsal quadrangular cartilage allowed the tip and upper lateral cartilages to assunne a more nornnal position, thus decreasing the upward rotation and slightly decreasing the projection. Figure 13-4C. Pre-op side view of patient with transition zone 2 deformity. This patient exhibits an excessively high dorsal border of the upper lateral cartilages, abnormally upwardly rotating the nose. Figure 13-4D. Post-op side view of reconstructed result. This patient underwent a reconstruction of transition zone 2 deformity outlined in Figure 6-1D. The judicious trimming of the excess upper lateral cartilage allowed the nose to rotate downward. Additionally a tip plasty was performed. Figure 13-4E. Pre-op 3/4 view of same patient. Figure 13-4F. Post-op 3/4 view of same patient.

Figure 13-4A

Figure 13-4B

Figure 13-4C

Figure 13-4D

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Figure 13-4F

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Figure 13-5 A - D . Reconstruction of Transition Zone 2 Deformity; I3-5E-F. Reconstruction of Transistion Zone 3 Deformity

Figure 13-5A. Pre-op side view of patient with transition zone 2 deformity. This patient exhibits an excessively high dorsal border of the upper lateral cartilages, abnormally upwardly rotating the nose. Figure 13-5B. Post-op side view of reconstructed result. This patient underwent a reconstruction of transition zone 2 defornnity outlined in Figure 6-1D. The judicious trimming of the excess upper lateral cartilage allowed the nose to rotate downward. Additionally a tip plasty was performed. Figure 13-5C. Pre-op 3/4 view of same patient. Figure 13-5D. Post-op 3/4 view of same patient. Figure 13-5E. Pre-op 3/4 view of patient with transition zone 3 deformity. This patient exhibits an upwardly rotated and excessively projected lower nose secondary to excess caudal septum (Figure 13-2E). Figure 13-5F. Post-op 3/4 view of reconstructed result. This patient underwent a reconstruction of transition zone 3 deformity outlined in Figure 13-2F

Figure 13-5A

Figure 13-5B

Figure 13-5C

Figure 13-5D

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Figure 13-5F

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Figure 13-6. Reconstruction ofTransistion Zone 3 Deformity

Figure 13-6A. Pre-op 3/4 view of patient with transition zone 3 deformity. This patient exhibits an upwardly rotated and excessively projected lower nose secondary to excess caudal septum (Figure 13-2E). Figure 13-6B. Post-op 3/4 view of reconstructed result. This patient underwent a reconstruction of transition zone 3 deformity outlined in Figure 13-2F Figure 13-6C. Pre-op 3/4 view of patient with transition zone 3 deformity. This patient exhibits an upwardly rotated and excessively projected lower nose secondary to excess caudal septum (Figure 13-2E). Figure 13-6D. Post-op 3/4 view of reconstructed result. This patient underwent a reconstruction of transition zone 3 deformity outlined in Figure 13-2F Figure 13-6E. Pre-op 3/4 view of patient with transition zone 3 deformity. This patient exhibits an upwardly rotated and excessively projected lower nose secondary to excess caudal septum (Figure 13-2E). Figure 13-6F. Post-op 3/4 view of reconstructed result. This patient underwent a reconstruction of transition zone 3 deformity outlined in Figure 13-2F

Figure 13-6A

Figure 13-6B

Figure 13-6C

Figure 13-6D

Figure 13-6E

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Figure 13-7. Reconstruction of Transistion Zone 3 Deformity

Figure 13-7A. Pre-op 3/4 view of patient with transition zone 3 deformity. This patient exhibits an upwardly rotated and excessively projected lower nose secondary to excess dorsal and caudal septunn, with deformity of the feet and legs of the tip cartilages. Figure 13-7B. Post-op 3/4 view of reconstructed result. This patient underwent a reconstruction of transition zone 3 deformity outlined in Figures 13-2F-I with additional excision of redundant dorsal cartilage. Figure 13-7C. Pre-op 3/4 view of patient with transition zone 3 deformity. This patient exhibits an upwardly rotated and excessively projected lower nose secondary to excess caudal septum, with deformity of the entire tip cartilages. Figure 13-7D. Post-op 3/4 view of reconstructed result. This patient underwent a reconstruction of transition zone 3 deformity outlined in Figure 13-2F-I with additional tip plasty as outlined in Figure 6-3D. Figure 13-7E. Pre-op 3/4 view of patient with transition zone 3 deformity. This patient exhibits an upwardly rotated and excessively projected lower nose secondary to excess caudal septum, with deformity of the feet and legs of the tip cartilages. Figure 13-7F. Post-op 3/4 view of reconstructed result. This patient underwent a reconstruction of transition zone 3 deformity outlined in Figures 13-2F-I with additional excision of redundant membranous columella as outlined in Figures 12-3C-D.

Figure 13-7A

Figure 13-7B

Figure 13-7C

Figure 13-7D

Figure 13-7E

Figure 13-7F

1111 ulllll ILII11 NASAL LIP

COMPLEX

SURGICAL ANATOMY The nasal configuration is by definition central to the theme of this book; however, the relationship of the nose to the adjacent structural elements of the face is also crucial to achieve a balanced and blended final result. The relationship of the nose with the lip is particularly important and is a cornerstone of facial beauty. In reality it is not so much the actual lip that is adjacent to the base of the nose, but the philtrum and soft tissues above the actual vermilion border of the true lip that most affects the nasal columella lip aesthetic complex. The midportion of the columella flows downward to a widening base, where there is a slight but definite junction demonstrated between the bottom of the nose and the superior-most aspect of the philtrum. The nasal sills also affect the areas just lateral to the philtrum. From a lateral perspective the nasal spine influences the projection of the area where the nose ends and the philtrum begins.

AESTHETICS The nose should show a definite demarcation between the nasal sill and the base of the columella and the beginning of the philtrum. There should be a sharp definite demarcation line between these two structures, when viewed from the front. From a lateral perspective, the nasal angle with the upper lip philtrum complex should also show a sharp demarcation and angles that are appropriate for each sex. Males in general look best with an angle approaching 90 degrees whereas females should be more upwardly rotated.

AESTHETIC PATHOLOGY The aesthetic pathology shows up in this area as an over- or underprojected nasal spine. The retracted nasal spine is discussed under the heading Retracted Columella in Chapter 10. Additional pathology shows up as an elongation of the distance between the base of the nose and the top of the vermilion border. This can be physically

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Mastering Revision Rhinoplasty eliminated by direct excision of skin above the vermilion, but this is not recommended due to the significant scarring that usually results from this technique. Alternatively, the upper lip can be filled out with a scalp dermal graft, which rotates the upper lip superiorly. The depressor nasi muscle also influences the nasal lip complex by its attachments from the nose to the lip. This muscle inserts in such a way as to inferiorly rotate the nasal tip and can even cause the tip to move in a downward motion with talking or smiling. Disruption of this muscle is needed to interrupt this downward influence.

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Figure 14-1. Reconstruction of the Nasal-lip Complex

Figure 14-1 A. Overprojected nasal spine. Overprojection of the nasal spine is usually associated with sonne excess of caudal septunn.This shows up as a heightened and tense upper lip connbined with an upwardly rotated nose with over projection. Figure 14-1B. Excision of overprojected nasal spine. UpperJhe nasal spine and caudal septunn are isolated via an interiorly extended transfixion. A scalpel begins the excision from above, moving interiorly until the bony hardness of the nasal spine is encountered. LowerJhe chisel then continues the dissection from superior to inferior using the same dissection plane initiated with the scalpel, but continuing through the nasal spine.The spine is loosened by a tangential cut of the chisel from anterior to posterior along the floor of the nose. Soft tissue attachments to the spine are excised with a Stevens scissors. Figure 14-1C. Corrected result. Nose is now able to move posterio-inferiorly into a more natural position. Figure 14-1D. Origins and insertions of depressor nasi musculature. The origins and insertions of the depressor nasi muscle system extend from the soft tissues of the muscle of the lip up into the septum and ramify along and actually onto part of the nasal tip cartilages. Figure 14-1E. Exposure and incision of depressor nasi muscle system. Upper: Exposure of the depressor nasi muscle system is through an extended transfixion incision.The scissors is brought through the incision from superiorly and the fibers are cut. This incision of the fibers must be quite superficial to guarantee that a majority of the fibers are cut, canceling their downward influence on the nasal tip. Lower. Nasal tip area is now released, allowing minimal movement of the tip with facial animation and release of nasal-lip complex. Figure 14-1F. Rotation and augmentation of upper lip; harvesting dermal graft. To improve the appearance of the nasal-lip complex, the distance from the base of the nose to the top of the vermilion border of the lip must be appropriately proportioned. As one ages this distance lengthens and gives the complex an unattractive appearance.The best way to decrease this distance is to rotate the upper lip upward by making it fuller Full-thickness scalp skin graft is harvested and de-epithelialized with the C 0 2 laser Alternatively a temporalis muscle graft can be used. Figure 14-1G. Upper lip augmentation. Upper. Incisions are placed on either side of the lip. A Stevens scissors is used to connect the incisions while tunneling through the orbicualris oris n\usc\e. Middle: An alligator forceps is fed through the tunnel and grabs the graft. LowerJhe incisions are closed with interrupted 6-0 chromic.The graft heals very quickly and becomes incorporated into the orbicualris oris very smoothly It thus accomplishes the dual result of augmenting and making the lip fuller while rotating the lip upward, thereby lessening the distance between the nose and the lip.

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Figure 14-2. Reconstruction of Nasal-lip Complex

Figure 14-2A. Pre-op lateral view of over-projected nasal spine. This patient exhibits overprojection of the nasal spine combined with sonne excess of caudal septunn (Figure 14-1 A). Figure 14-2B. Post-op lateral view of corrected result. This patient underwent excision of the overprojected nasal spine and excess caudal septunn (Figures 14-IB-C). Figure I4-2C. Pre-op 3/4 view of same patient. Figure 14-2D. Post-op 3/4 view of same patient. Figure 14-2E. Pre-op lateral view of patient with strong depressor nasi muscle influence. This patient exhibits a strong depressor nasi muscle causing the nasal tip to interiorly rotate and to depress upon speaking (Figure 14-1D). Figure 14-2F. Post-op lateral view of corrected result. This patient underwent incision of the depressor nasi muscle (Figure 14-1E).

Figure 14-2A

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Figure 14-3. Reconstruction of Nasal-lip Complex (Rotation and Augmentation of Upper Lip)

Figure 14-3A. Pre-op frontal view of patient with thin upper lip. This patient exhibits a thin upper lip detracting from the nasal-lip connplex. Figure I4-3B. Post-op frontal view of corrected result. This patient underwent augnnentation of the upper lip. Note that the entire nasal-lip connplex is enhanced and the distance fronn the top of the lip to the nose is shortened due to the upper lip superior rotation. Figure 14-3C. Pre-op frontal view of patient with thin upper lip. This patient exhibits a thin upper lip detracting fronn the nasal-lip connplex. Figure 14-3D. Post-op frontal view of corrected result. This patient undenyvent augnnentation of the upper lip. Note that the entire nasal-lip connplex is enhanced and the distance fronn the top of the lip to the nose is shortened due to the upper lip superior rotation. Figure 14-3E. Pre-op 3/4 view of patient with thin upper lip. This patient exhibits a thin upper lip detracting from the nasal-lip connplex. Figure I4-3F. Post-op 3/4 view of corrected result. This patient underwent augnnentation of the upper lip. Note that the entire nasal-lip connplex is enhanced and the distance fronn the top of the lip to the nose is shortened due to the upper lip superior rotation.

Figure 14-3A

Figure 14-3B

Figure 14-3C

Figure 14-3D

Figure 14-3E

Figure 14-3F

W] T I P INTRODUCTION AND ANATOMY

TIP RECONSTRUCTION Surgical manipulation of the nasal tip is the most challenging area of reconstructive rhinoplasty. The elegantly complex anatomic form of the lower lateral cartilages framed by the draping soft tissue of the alar and nostrils is so exquisitely balanced that it is very difficult to correct, once an iatrogenic mistake has been made. These structures are particularly sensitive to the complexities of scarring, which can act to cause contour depressions and hypertrophic convexitites. The intense pulling and distortion of these delicate cartilaginous and soft tissues by the scar contracture itself often leaves some residual permanent deformity, even after the best of reconstructive efforts. Correction of these iatrogenic deformities will be discussed next in logical outline, beginning with minor deformities and ending with the major reconstructions.

SURGICAL ANATOMY The anatomical nomenclature that serves to describe the tip cartilages has always been complicated. Since it is necessary for the surgeon to have a crystal clear idea of this anatomy and because I believe that the anatomical nomenclature used to describe the tip is at best confusing, I have redefined the nomenclature for use in this text.

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Figure 15-1. Surgical anatomy of the tip cartilage I believe that the most accurate and clearly understood analogy for the complex shape of the tip cartilages is the human body (homonculus). Imagine two paired human bodies flexed at the waist with arms arched outward in front of the head, as if diving into a pool. Keeping this vision in mind, compare the two terminologies:

1. 2. 3. 4. 5.

Previous terminology

New terminology

Structural support

Medial crus Feet of medial crus Middle crus Lateral crus Dome

Legs Feet Body Arms Dome

Columella Base of columella Tip (medial) Tip (lateral)

Thus the tip cartilages can be envisioned as two divers arched back to back, with their legs and buttocks touching, their legs straight, bent at the waist, with their arms arched in front of them over their head. Comparison of Previous and new terminology. As a point of reference it is best to describe the curving diving homonculus with its feet at the base. Continuing superiorly the medial crus will be called the legs and the lateral crus will be the outstretched arms of the homonculus, with the head tucked in between.The confusing middle crus will now be termed the body of the tip cartilages and will have various angulations and bends depending on the particular patient. Note:Jhe terminology in describing the dome is archaic and clinically useless. Almost every refinement and manipulation of the tip cartilages will effect the dome, and it is not necessary to exactly describe this in terms of an anatomic entity except to say that it describes the high point or the most projected point from the plane of the face.

Technique

15-lB

15-lA

15-lC

'

15-lD

209

r TIP

MEDIALIZATION

The ability to medialize the overall tip area is an essential component of many revisions. One can incorporate into the concept of medialization: refinement, thinning etc.; however, all these descriptive elements have in common the act of making the tip cartilages come together, or more accurately, medialize. Many techniques have been published that deal with this particular problem. The techniques presented here share the dual characteristics of simplicity and effectiveness. In revisional rhinoplasty these two entities will allow for a more predictable outcome. This tenet is of course a basic concept of revisional rhinoplasty. Described another way, it is important only to advance and enhance the natural characteristics of the nose, and never to take a step backward, by judiciously avoiding ineffective techniques.

AESTHETIC PATHOLOGY Although it is easy to recognize a tip that is too wide, it is much more problematic and important to identify the underlying aesthetic pathology. The etiologic entities outlined below will serve to introduce the various elements that contribute to the wide/boxy/lateralized tip.

I • Malposition of Normally Shaped Cartilages In this category the tip cartilages are normally or near normally shaped but appear wide or boxy due to a positional problem. la. The tip cartilages are of normal size and shape but are attached to the soft tissue envelope in such a way that the arms of the cartilages are being pulled too far laterally. Simple undermining of the superficial and vestibular skin will correct this problem. l b . The tip cartilages are within normal limits for size and shape but are being pushed apart laterally. Usually there is a mass of tissue in between the "body" of the cartilages that are widening the tip. In this case, not only do the tip cartilages have to be dissected from the soft tissue envelope and repositioned, but also the mass of tissue separating the tip cartilages must be removed to allow for this reposition.

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2. Improperly shaped cartilages 2a. The tip cartilages are of proper proportion and size: however, the angle of the cartilages at the "body" is too obtuse causing the "arms" to be higher and more superior than normal. In this case a simple "rebending" of the tip cartilages will decrease the angle at the "body" allowing the arms of the cartilages to relax and not be so elevated or projected. This will also redefine the dome. No other adjustments are necessary to correct this type of deformity. 2b. The tip cartilages are the right size overall, but the body is too wide and misshapen. Reconstruction in this case is performed by "redefining" the dome, borrowing and sculpting the cartilage so it becomes either a new part of the arm or the leg or both of the tip cartilage, whichever is more appropriate in each individual case. The "borrowing" of tissue is also dependent upon projection. If the nasal tip needs more projection, then the new tip borrows tissue from the arm to become the body, thus adding projection. If less projection is desirable, then the medialization occurs by taking tissue from the leg, thus decreasing the projection. 2c. The arms of the tip cartilages are too long. The dome is correctly positioned and in good proportion with the normally sized feet and legs. Reconstruction in this case is a simple trimming of the arms of the tip cartilage. 2d. The projection of the tip is within normal limits; that is, the height of the legs of the tip cartilages is normal, however, the angle of the body is too obtuse and the arms are too bulky and too long. This reconstruction requires a total medialization and reduction of the cartilaginous components. Note that in these kinds of tips, invariably the soft tissue envelope offers significant support to the lower one-third of the nose and could most likely exist without collapsing, even without any or very little tip cartilages for support. The concept in these cases is to reduce and reangulate the arms of the tip cartilages so that they float in the soft tissue envelope without being too strong. Most of these tips not only have strong and supportive soft tissue envelopes, but they have very strong and highly curved tip cartilages. The ideal of the reconstructive effort is to match the size and shape of the tip cartilages with the newly designed proportions of a medialized nose. As in any entity of medicine, the outcome will be more successful if a correct diagnosis is made. In revisional rhinoplasty of tip, the diagnosis is particularly essential in pointing to the most advantageous technique, which will be utilized to effect the most predictable outcome. After the correct diagnosis is made, and sometimes this is impossible to predict until after a full intraoperative exposure of the anatomical elements is secured, the simplest technique, which will effect the reconstruction, should be chosen.

Technique

213

TECHNICAL CONCEPTS OF RECONSTRUCTION The first tenet of tip medialization is to do as little to the actual tip cartilages as possible. By maintaining their integrity you ensure a more natural reconstruction. Thus, for example, if the tip cartilages can be manipulated within the soft tissue envelopes without actually touching the cartilages, and just allowing them to slide within this envelope in a more medial direction, then this is preferable to making extensive changes in the tip architecture. Oftentimes this technique should be attempted primarily to get a sense of how the tip cartilages will position themselves after freeing them from their surrounding soft tissues directly, before progressing to more aggressive techniques. The basic tenet is, of necessity, "less is more," and the less dissection and manipulation of the tissues, the better the ultimate result will be. Once it has been determined that cartilage manipulation is necessary, appropriate modification of these delicate structures should commence with morselization, and thinning techniques before jumping to actual excisions. Combination techniques of thinning, morselization and excision are also very effective in medialization and decreasing projection. It is important to note that the soft tissue envelope that surrounds the actual tip cartilages has a significant role to play in their shape. Because of the dense approximation of the internal vestibular skin and the outer skin of the alar region to the tip cartilages themselves, this envelope influences the shape and curvature of these cartilages. Thus in certain instances it is sometimes necessary to complete a LeGuard maneuver to expose the cartilages and let their intrinsic shape materialize without the encumbrances of the soft tissue envelope.

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Figure 16-1 .Techniques of Tip Medialization for Malpositioned Normally Shaped Cartilages

Figure 16-1 A.Tip cartilages pulled laterally by soft tissue envelope. The tip cartilages are normal in size and shape, but are pulled apart laterally by the soft tissue and ligannentous "envelope.'The lighter colored blue tip cartilage depicts the lateralized preoperative position of the tip cartilages, while the darker blue illustrates the nnedialization that occurs after release of the soft tissues as performed in Figures 16-1B and 16-1C. Figure 16-1B. LeGuard technique for release of tip cartilages. A modified LeGuard technique is used to release the tip cartilages from the ligamentous attachments laterally, by cutting the ligaments from their insertions into the lateral edge of the tip cartilages. Release of the external surface of the tip cartilages from the skin along the entire plane of the tip cartilages is performed via rim incisions anteriorly and posteriorly through an intercartilaginous approach.Jhis usually suffices to medialize the tip cartilages. Sometimes the maneuver can be carried out through the posterior approach only obviating the need for a separate rim incision. Figure 16-1C. Complete leguard technique for release of tip cartilages. If the technique shown in Figure 16-1B does not fully readjust the tip cartilages medially then a complete "degloving" of the tip cartilages from the soft tissue envelope may be necessary This is accomplished by combining the modified LeGuard maneuver with a dissection of the vestibular skin internally to totally free the arms and body of the alar cartilages. Figure 16-1D. Corrected result (lateral view). After release of the soft tissue envelope, the cartilages are released and free to medialize. Tip cartilages in light blue depict position before medialization technique and dark blue is final corrected result. Figure 16-1E. Corrected result (base view). Base view better depicts the medialization of the tip cartilages and the resultant thinning of the tip with a slight increase in tip projection. Figure 16-1 F.Tip cartilages pushed laterally by fibro-fatty soft tissue. Another reason for laterally displaced tip cartilages is a mass of fibro-fatty tissue situated between the "bodies" of the tip cartilages, pushing the entire tip cartilages in a lateral direction. Figure 16-1G. Complete degloving of tip cartilages and exposure of fibro-fatty tissue. Approach to this reconstruction is through rim incisions with a complete degloving of the internal and external layers of skin surrounding the tip.The cartilages are delivered and the fibro-fatty tissue is excised.

Technique 2 1 5

16-lA

16-lC

16-lB

16-lD

16-lF

16-lE

16-lG

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Figure 16-2A-16-2D.Techniques of Tip Medialization for Malpositioned but Normally Shaped Cartilages (continued); 16-2E-G. Reconstruction of Boxy W i d e Tip with Digital Pressure

Figure 16-2A. Fixation of released and medialized tip cartilages. After the cartilages are completely released and the fibro-fatty tissue is removed, fixation of the cartilages is performed by applying cartilage adhesive to the inner (medial) aspects of the bodies of the tip cartilages for approximation and fixation of this area, thus medializing and securing the position of the entire tip cartilage complex. Interdomal suturing techniques can alternatively be used. Figure I6-2B. Fixation of arms of tip cartilages to superficial skin. Additional cartilage adhesive is placed between the superficial aspect of the cartilage and the skin. Figure I6-2C. Fixation of arms of tip cartilages to vestibular skin. A Q-tip is used to approximate the previously glued surfaces. Additional cartilage adhesive is now placed between the deep aspect of the cartilage and the vestibular skin. Final application of Q-tip to squeeze together and refuse the skin layers to the newly medialized cartilage before sutures are placed to close the rim incision. Figure 16-2D. Corrected result. Medialized cartilages are secured in multiple locations to each other and to the soft tissue envelope with tissue adhesive. Intracartilaginous sutures are generally unnecessary although they can be used if desired. Figure 16-2E. Boxy wide tip secondary to obtuse angle within cartilage body. In this example, the curvature of the body of the tip cartilage is too obtuse, causing the arms to rise too high from the plane of the face. Correction of deformity by altering this angle to a more acute degree will decrease the boxiness and width of the tip. Note that the actual size of the tip cartilages is within normal limits. Figure 16-2F. Digital pressure reconstruction. Simple digital pressure at the body of the tip is often all that is needed to "break the spring" of the body and allow the arms to lower themselves toward the plane of the face.The pressure actually causes the cartilage to crack minutely and in a very gentle way It is almost impossible to exert too much digital pressure on the cartilages, so a fairly firm attempt repeated several times may be necessary to effect the correct decrease in the angle. Figure 16-2G. Corrected result. Medialized thinner tip is evident after digital pressure.

Technique

16-2A

16-2B

16-2C

16-2E

16-2D

16-2F

16-2G

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Figure I 6 - 3 A - C , Medialization of Boxy W i d e Tip Via Direct Morselization of the Body of the Tip Cartilage; 16-3 D-R Medialization Via Direct Excision; I6-3G-I. Medialization Via Combined Technique of Excision of Lateral Edge of A r m and Cephalic Border of Tip Cartilage with Morselization of Lateral Edge

Figure 16-3A. B o x / wide t i p secondary t o obtuse body angle (area of morselization). If the cartilages will not respond to simple digital pressure, then direct exposure of the body through a rim incision with just enough of a tunnel to allow the entrance of a fine hemostat into the area of the body should be attempted nextThis will in many cases suffice to "bend" the cartilage and correct the width and boxiness of the tip.The morselization is performed within the stippled area. Figure I6-3B. Exposure of body of t i p cartilage. A low rim incision over the area of the body is used to expose the area to be morselized.A small delicate hemostat is used to gently crush and bend the cartilage to the desired angle. Figure 16-3C. C o r r e c t e d result. The morselization has "rebent" the tip cartilages thus decreasing the angle at the "body," lowering the arms of the cartilages, resulting in medialization and a loss of projection.This maneuver will also by definition, redefine the dome. Figure 16-3D. Boxy wide t i p secondary t o obtuse body angle (area of excision). If the above techniques prove inadequate, then the most direct and foolproof method of readjusting the angle of the body of the tip cartilage is to actually excise a strip of cartilage.This excision should be fairly medial so that the curvature of the cartilage that will become the dome is smooth and has a pleasing curvature.The cut should be approximately at the level of the leg-body junction. Figure I6-3E. Excision of t i p cartilage at t h e leg-body junction. The leg-body junction of the tip cartilage is exposed via a low medial rim incision.The cartilage is dissected free of the superficial and vestibular skin. A strip of cartilage is excised. Figure 16-3F. Corrected result. The transection of the tip cartilage at the leg-body junction has resulted in a medialization and subsequent refinement of the tip. Figure 16-3G. Medialization of t i p cartilages by excision of lateral edge of a r m . In this scenario the size and proportion of the body and legs are within normal limits, as is the angle of the body The arms, however; are simply too long and must be readjusted medially by direct excision: (I) shows area of routine cephalic edge excision; (2) shows area to be excised; (3) shows area to be morselized. Figure I6-3H. Exposure, excision and morselization of a r m of t i p cartilage. Exposure for excision of lateral arms is via a rim incision and total dissection of the lateral edge of the tip cartilage.The excision is angled so that the longest part of the lateral edge is inferior; which adds support to the alar without adding lateral bulkThe new lateral edge is thinned gently with the tip of a delicate hemostat to avoid a distinctly visible edge showing through the skin. Figure 16-31. Corrected result. The excision of the lateral arm has resulted in a medialization and refinement of the tip. Right side of tip shows newly reconstructed tip superimposed on original tip. Left side shows only newly reconstructed tip.

Technique

2-36/3,

aesthetics, 107

of bilateral middle nasal-vault collapse, 3 7 2 - 3 7 3

deformities of, 25

combination collapse, 3

internal nasal-valve reconstruction, 137-138,142-143

unilateral, 2i>^-25? 7

294-297

for middle nasal-vault, 11-IS

Total nasal-tip replacement, 32()-32 7

nasal-lip complex, 197

Total-tip and middle nasal-vault titanium reconstruction,

nasal-tip, 207,208-209

320-321

pertinent details in, 20

Transition zones, 179-195

septum, 107

aesthetic pathology, 180

titanium nasal reconstruction, 301

aesthetics, 179-180

transition zones, 179

reconstruction of, technical concepts of, 180-181 reconstruction of zone 1 deformities,

T Technical errors, 13-14 Thyroid, control of, prior to revision rhinoplasty, 5 Timing of previous surgeries, 14

Tissues, anoxia of, 9 Titanium, 301

184-191

reconstruction of zone 3 deformities,

184-185,

190-195 Treatment, planning and, 8 True cyst formation, 78

of revisional rhinoplasty, 9-11 Tissue clay augmentation,

reconstruction of zone 2 deformities,

surgical anatomy, 179

of multiple revisions, 10-11

358-359

182-183

Turbinates, 26 hypertrophic, 26 inferior, 30

394

Index

U Unilateral bony vault collapse, 302-303 Upper lateral cartilage in defining nasal rotation, 150 Upper lip, rotation and augmentation of, 200-201, 204-205

V Vermilion border, 197 Vitamin therapy, preoperative regimen of, 5

w Wound healing, 13