Primary Rhinoplasty

Author Credentials 

Samuel Oyer, MD
Assistant Professor
Facial Plastic & Reconstructive Surgery
Department of Otolaryngology-Head & Neck Surgery
Medical University of South Carolina
Phone: 843-876-5039
Oyer@musc.edu

Module Learning Objectives 
  1. Describe the anatomy and nasal proportions relevant to rhinoplasty.
  2. Summarize the benefits and limitations to rhinoplasty approaches.
  3. Describe techniques to address the nasal dorsum both reduction and augmentation.
  4. Name the supporting mechanisms of the nasal tip and describe alterations to tip rotation and projection with various surgical maneuvers.

 

Anatomy

Bone  

  1. Cite that the soft tissues of the nose project forward from a stable bony base made up of:
  • Paired nasal bones, paired frontal process of the maxilla, central maxillary bone and nasal spine caudally

Cartilage 

  1. Review that it provides flexible support to nasal skin and valves.
  • Paired upper lateral cartilages (ULC). Connect to nasal bones and dorsal septum
  • Paired lower lateral cartilages (LLC).  Connect to ULC at scroll and to caudal septum

Skin & soft tissue envelope (SSTE) 

  1. Recognize that: thin skin over dorsum, thicker skin over nasal tip
  • Vascularity supplied by branches of angular and lateral nasal arteries bilaterally
  • Vessels run in superficial musculo-apneurotic system (SMAS) along with nasal muscles
  • Dissection should be deep to SMAS to preserve vascularity of skin in avascular plane

Septum

  1. Explain that it provides primarily structural support for nasal cartilage framework
  • Quadrangular cartilage: connects nasal dorsum to nasal spine and maxillary crest
    • Structural integrity of nose requires preservation of 1-1.5cm wide “L-strut” along the dorsal and caudal edge of the septal cartilage
  • Bony septum: Vomer and perpendicular plate of ethmoid
    • Keystone: Junction between quadrangular cartilage and ethmoid bone along the dorsal septum underneath the nasal bones.  Must preserve or reconstruct to avoid saddle nose

 

References

  1. Paquet CA, Pepper JP. Tip Rhinoplasty. In: Desai SC, ed. Facial Plastic and Reconstructive Surgery Clinical Reference Guide. San Diego: Plural Publishing, Inc.; 2017.
  2. Cingi C, Muluk NB, Ulusoy S, et al. Nasal tip sutures: Techniques and indications. Am J Rhinol Allergy. 2015;29:e205-e211.
  3. Apaydin F. Projection and Deprojection Techniques in Rhinoplasty. Clin Plast Surg. 2016;43:151-168. 
  4. Walker TJ, Toriumi DM. Philosophy and Principles of Rhinoplasty. In: Papel ID, Frodel JL, Holt GR, Larabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York: Thieme; 2016.
  5. Daniel RK. Mastering Rhinoplasty: A Comprehensive Atlas of Surgical Techniques. 2nd ed. New York: Springer; 2010.
Nasal proportions
  1. Explain that the optimal nasal aesthetics must account for individual ethnicity and facial harmony
  • Facial fifth: Nasal base width (ala-ala) = one facial fifth = intercanthal distance
  • Facial third: Nasal height from glabella to subnasale = one facial third
  • Nasofrontal angle: Glabella to nasion to dorsum. Ideal = 120˚ (range 115-135)
  • Naso-facial angle: Vertical line from glabella to pogonion compared to dorsum. Ideal = 36˚
  • Nasolabial angle: Upper lip to subnasale to nasal tip. Ideal = 90-95˚ (men); 95-105˚ (women) 
  • Nasomental angle: Glabella to nasal tip to chin (pogonion). Ideal = 120-130˚
  • Tip projection: Defines extent that tip extends forward from the face
    • Simons: length of upper lip (vermilion to subnasale) = length of tip (subnasale to tip)
    • Goode: right triangle with vertical limb from nasion to alar groove. Ratio of tip projection relative to dorsal length = 0.55-0.6
    • Crumley: right triangle similar to Goode with sides measuring 3:4:5
  • Columellar show: Normal range 2-4mm
  • Base view: Tip appears as isosceles triangle. Lobule to columellar height ratio = 1:2
  • Chin projection: Anterior limit of pogonion is vertical line from glabella.
    • Consider chin position when evaluating dorsal projection and facial harmony

Reference

  1. Ishii LE. Aesthetic Facial Proportions. In: Papel ID, Frodel JL, Holt GR, Larabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York: Thieme; 2016.
Surgical approaches
  1. Endonasal rhinoplasty (Closed approach): Intranasal incisions only
  • Summarize the pros: Less dissection & disruption of support structures ⇒ Less edema & faster recovery. No external scar.
  • List the cons: Decreased visualization and more difficult to place grafts/sutures, steeper learning curve
    • Marginal incision: cephalic margin of LLC
    • Intracartilaginous incision: made within lateral crura at desired level of cephalic trim
    • Intercartilaginous incision: made at scroll between LLC and ULC
    • Hemi-transfixion or Killian incision: separate access to septum for septoplasty
  1. External rhinoplasty (Open approach)
  • Summarize the pros: Better visualization and access for graft placement, direct access to septum
  • List the cons: More disruption of support structures, more soft tissue swelling, columellar scar
    • Marginal incision combined with columellar incision

 

References

  1. Paquet CA, Pepper JP. Tip Rhinoplasty. In: Desai SC, ed. Facial Plastic and Reconstructive Surgery Clinical Reference Guide. San Diego: Plural Publishing, Inc.; 2017.
  2. Cingi C, Muluk NB, Ulusoy S, et al. Nasal tip sutures: Techniques and indications. Am J Rhinol Allergy. 2015;29:e205-e211.
  3. Apaydin F. Projection and Deprojection Techniques in Rhinoplasty. Clin Plast Surg. 2016;43:151-168. 
  4. Walker TJ, Toriumi DM. Philosophy and Principles of Rhinoplasty. In: Papel ID, Frodel JL, Holt GR, Larabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York: Thieme; 2016.
  5. Daniel RK. Mastering Rhinoplasty: A Comprehensive Atlas of Surgical Techniques. 2nd ed. New York: Springer; 2010.
Nasal Dorsum Rhinoplasty
  1. Dorsal hump reduction: accessible through endonasal or open approach
  • Explain component hump reduction: Reduce bone and cartilaginous portion of hump separately
    • Cartilaginous hump involves dorsal septum and ULC—sharp resection 
    • Bony hump involves medial nasal bones and some bony septum
      • Osteotomes or rasps commonly utilized
  • Describe dorsal reconstruction
    • Open roof deformity: created following large bony hump reduction
      • Treat with lateral osteotomies to medialize nasal bones
    • Middle vault
      • Secure ULC to dorsal septum +/- spreader grafts if needed

 

  1. Correction of deviated dorsum: Most easily accomplished through open approach
  • Review cartilaginous deviation
    • Requires first addressing underlying septal deviation
    • Septal scoring, septal batten graft, extended spreader graft or asymmetric spreader grafts, and differential suturing to ULC can improve dorsal straightness
  • Explain bony deviation: Requires oteotomies
    • Medial: continuous osteotomy extending from caudal edge of nasal bone just lateral to septum that travels cephalically and fades laterally
      • 1st osteotomy performed, separates medial nasal bones
      • Should not traverse into firm frontal bone (rocker deformity)
    • Intermediate: perforating percutaneous osteotomy that parallels medial osteotomy in the mid nasal bone
      • 2nd osteotomy performed if needed
      • Used unilaterally on convex side of deviated dorsum to straighten
    • Lateral: continuous or perforating osteotomy through ascending process of maxilla to junction with nasal bones
      • 3rd osteotomy performed in sequence
      • Mobilizes nasal bone to close open roof deformity or shift dorsum
      • Start high on the pyriform bone to preserve attachment of inferior turbinate and extend to level of medial canthus
      • Transverse: perforating percutaneous osteotomy in axial plane at the cranial aspects of medial and lateral osteotomies
        • Last osteotomy performed if needed to fully mobilize nasal bones

 

  1. Explain dorsal augmentation: 
  • Structural deficiency requires adequate reconstruction of the septal L-strut along with augmentation of the dorsal projection
  • Isolated aesthetic deficiency can be addressed with onlay grafting or implants 
    • Minor deficiency: Precise pocket dissection through endonasal approach 
      • Autogenous material generally preferred:
        • Septal cartilage, auricular cartilage, diced cartilage in fascia or fibrin glue
    • Major deficiency: Open approach provides better exposure for graft/implant placement
      • Autogenous grafting
        • Stacked septal or auricular grafts, diced cartilage in fascia or fibrin glue, solid costal cartilage graft, calvarial bone graft
      • Homologous grafts
        • Cadaveric costal cartilage (cryo or chemically preserved)
      • Alloplastic implants: Avoids donor site morbidity but risks infection/extrusion
        • Should not be used for structural grafts
        • Silicone, Medpore®, Gortex®

 

References

  1. Paquet CA, Pepper JP. Tip Rhinoplasty. In: Desai SC, ed. Facial Plastic and Reconstructive Surgery Clinical Reference Guide. San Diego: Plural Publishing, Inc.; 2017.
  2. Cingi C, Muluk NB, Ulusoy S, et al. Nasal tip sutures: Techniques and indications. Am J Rhinol Allergy. 2015;29:e205-e211.
  3. Apaydin F. Projection and Deprojection Techniques in Rhinoplasty. Clin Plast Surg. 2016;43:151-168. 
  4. Walker TJ, Toriumi DM. Philosophy and Principles of Rhinoplasty. In: Papel ID, Frodel JL, Holt GR, Larabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York: Thieme; 2016.
  5. Daniel RK. Mastering Rhinoplasty: A Comprehensive Atlas of Surgical Techniques. 2nd ed. New York: Springer; 2010.
Nasal Tip Rhinoplasty
  1. Explain the Tip Support Mechanisms:
  • Major:
    • Size, shape, and resilience of LLC
    • Medial crural footplate attachment to caudal septum
    • Scroll region between LLC and ULC
  • Minor:
    • Intradomal ligament
    • Cartilaginous dorsal septum
    • Membranous septum
    • Nasal spine
    • Sesamoid cartilages from the lateral crura to pyriform aperture
    • Skin and soft tissue overlying LLC
  • Tripod theory: paired medial crura and each lateral crura form three legs of a tripod.  Lengthening or shortening any leg impacts tip rotation/projection
    • Shortening medial crura: ↓ rotation and ↓ projection
    • Lengthening medial crura: ↑ rotation and ↑ projection
    • Shortening lateral crura: ↑ rotation and ↓ projection
    • Lengthening lateral crura: ↓ rotation and ↑ projection
  1. Discuss tip rotation & projection
  • Tip projection/rotation is influenced by the position of the medial crura relative to the caudal septum, and the tripod theory
    • Maneuvers that increase tip projection
      • Advancing the medial crura relative to caudal septum (tongue-in-groove, caudal septal extension graft, columellar strut)
      • Recruiting lateral crura to increase length of medial crura (lateral crural steal, intradomal suture)
      • Advancing lateral crura (will ↓ rotation unless medial crura also advanced)
        • Lateral crural strut or batten grafts, lateral crural spanning suture
      • Augmenting nasal domes (intradomal suture, tip graft)
    • Maneuvers that decrease tip projection
      • Positioning medial crura more posteriorly relative to caudal septum (tongue-in-groove, caudal septal shortening)
      • Shortening medial or lateral crura (medial/lateral crural overlay, vertical dome division)
    • Maneuvers that increase tip rotation
      • Lengthening medial crura relative to lateral (medial crural steal, lateral crural overlay)
      • Changing position of medial crural relative to caudal septum (tongue-in-groove, caudal septal extension widest at posterior septal angle)
      • Creating the appearance of increased rotation (pre-maxillary plumping grafts, dorsal reduction)
    • Maneuvers that decrease tip rotation
      • Shortening medial crura relative to lateral crura (medial crural overlay, lateral crural reposition with strut grafts)
      •  Changing position of medial crura relative to caudal septum (tongue-in-groove, caudal septal extension graft widest at anterior septal angle, nasal spine reduction)
      • Creating the appearance of decreased rotation (shield graft, dorsal augmentation)
  1. Describe tip/nasal base reduction & refinement
  • Tip defining points = paired light reflexes seen on nasal skin that mark position of underlying nasal domes (roughly 8-10mm between points)
    • Angle of divergence between domes = 60˚

 

  • Cartilage reduction/weakening
    • Cephalic trim: resection of cephalic portion of lateral crura maintaining 6-8mm of lateral crural height for stability. Reduces supratip fullness. Slightly ↑ rotation
    • Cartilage scoring: weakens overly strong LLC to improve symmetry and allow cartilage to be shaped more easily with suture techniques
    • Vertical dome division: complete division of LLC at domes with repositioning and suture repair of medial and lateral crura. Can produce over narrowed “pinched tip”
  • Tip sutures: Used to reshape LLC
    • Interdomal: Placed between the domes to improve symmetry and narrow the domes.  Can create over-narrowed infratip if angle of divergence is not maintained.
    • Intradomal: Horizontal mattress suture starting medially from medial to lateral crura
      • Increases convexity of the domes and slightly ↑ tip projection
    • Lateral crural sutures: spanning and flaring sutures between lateral crura
  • Tip grafts: ↑ projection/definition along with suture techniques
    • Tip graft: placed over domes to augment nasal tip (commonly 8-10mm wide).  
    • Shield graft: placed from tip to infratip or columella
    • Cap graft: supporting graft between shield graft and domes
    • Rim graft: Thin graft placed in precise pocket along alar rim to straighten & support

 

  • Nasal base reduction
    • Final maneuver performed after all dorsum and tip work done and the incisions closed
    • Careful measurement and suturing is mandatory to avoid unsightly scars or over-narrowing
    • Excess alar width: distance between the alar insertion to the cheek > intercanthal distance
      • Nostril sill excision: vertically based trapezoidal wedge to narrow sill
    • Excess alar flare: nostril flares laterally from normal attachment point
      • Alar wedge excisions (Weir): fusiform shaped wedge with the lateral extent <1mm from alar-facial groove and medial extent varied based on tissue excess
    • Excess width and flare: combine alar wedge excision with nasal sill excision creating alar advancement flap

 

References

  1. Paquet CA, Pepper JP. Tip Rhinoplasty. In: Desai SC, ed. Facial Plastic and Reconstructive Surgery Clinical Reference Guide. San Diego: Plural Publishing, Inc.; 2017.
  2. Cingi C, Muluk NB, Ulusoy S, et al. Nasal tip sutures: Techniques and indications. Am J Rhinol Allergy. 2015;29:e205-e211.
  3. Apaydin F. Projection and Deprojection Techniques in Rhinoplasty. Clin Plast Surg. 2016;43:151-168. 
  4. Walker TJ, Toriumi DM. Philosophy and Principles of Rhinoplasty. In: Papel ID, Frodel JL, Holt GR, Larabee WF, Nachlas NE, Park SS, Sykes JM, Toriumi DM, eds. Facial Plastic and Reconstructive Surgery. 4th ed. New York: Thieme; 2016.
  5. Daniel RK. Mastering Rhinoplasty: A Comprehensive Atlas of Surgical Techniques. 2nd ed. New York: Springer; 2010.
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