Abstract: Techniques in Rhinoplasty

To: Mark Clymer, MD

By: Stephen W. Perkins, MD

Fellowship Director Sequel to Abstract by Steven Dayan, M.D.

RE: Abstract: Techniques in Rhinoplasty

Approximately six or seven years ago I had the pleasure and opportunity to have Dr.

Steve Dayan spend the year with me as a fellow in my practice at the Meridian Plastic

Surgery Center in Indianapolis, Indiana. Rhinoplasty procedures constituted

approximately one-third of my facial plastic surgery practice at the time Steve was with

me and continues to be about twenty-five to thirty-five percent of my total practice

volume. I am still performing the same number of rhinoplasties on an annual basis as I

did eleven years ago, but other aging face procedures, with particular emphasis on

increasing numbers on lesser invasive procedures, have grown within the practice.

Rhinoplasty is and always has been the most challenging facial plastic surgery

procedure that I perform and remains the most difficult procedure to teach young

developing facial plastic surgeons. I agree with Dr. Dayan that rhinoplasty is a highly

complex procedure which he describes as having a steep learning curve. My opinion

differs because I believe that rhinoplasty is an operation that has one of the least steep

learning curves of all the procedures we do. It takes an entire career to even begin to

learn the nuances of the rhinoplasty operation and even longer to consistently predict its

long-term results. Aging face procedures are picked up fairly rapidly with a very steep

learning curve which allows the finishing fellow in my fellowship to leave the practice

well prepared to perform most any aging face procedure that we do. Whereas, most of

the fellows are still trying to get a feel for how to execute the multitude of techniques that

make a difference between good and excellent rhinoplasty results.

Rhinoplasty remains a very humbling operation even for the more experienced

surgeons who are considered masters in the field. Over the past six to ten years, my

personal abilities to perform this operation have exponentially increased compared to the

first two-thirds of my years in private practice. Most of this is due to the critical

evaluation of the results of rhinoplasties I performed years ago. At that time, I believed I

was doing very appropriate surgical maneuvers taught by my mentors, who were very

experienced rhinoplasty surgeons themselves. In addition, I have continued to be a

student of the operation and have attended every rhinoplasty meeting that the Academy

has offered and have participated as a faculty member as well. Every time I attend a

meeting I improve my skills and abilities to recognize potential problems in rhinoplasty

as well as adding modified, if not new, procedures to improve the overall long-term

results. As one of the more mature surgeons, with twenty plus years of experience, I have

been afforded the opportunity to see and examine long term results from my own practice

experience. Many times patients return to me and the practice for some other facial

plastic surgery concern, such as aging face, and have been satisfied, content, and

essentially happy with their rhinoplasty results. However, I would evaluate some of these

results from a surgeon’s perspective and react with a certain degree of “horror”.

Changes that occurred over time demonstrated that reduction rhinoplasty needs to be

extremely conservative and many of the things that I believed and were taught needed to

have another critical assessment. My rate of revision rhinoplasty still is between three

and five percent of my rhinoplasty practice, as it was six to seven years ago. If I were to

choose for the patient, my revision rate would probably rise to twenty-five to thirty

percent of the rhinoplasties I performed greater than ten years ago. Within my practice,

revision or secondary rhinoplasty still is only about thirty-five to forty percent of my

total number of rhinoplasties.

Often patients do not know that a revision can be performed which could give them

more satisfactory results. In addition, they often have had an uncomfortable, if not

miserable, experience from the first operation and do not believe they want to undergo

another one. Furthermore, the cost of the revision rhinoplasty is more than a primary

rhinoplasty and significantly more than they paid several years ago. These factors limit

the total numbers of secondary rhinoplasties that could be performed.

Secondary rhinoplasty affords us the opportunity to learn from what we see as “others’

mistakes”, but we also learn from our own by following patients for at least ten years and

longer. My basic philosophical approach to the rhinoplasty operation is essentially the

same as it was when Dr. Dayan spent a year in fellowship with me. My personal

approach to the rhinoplasty operation involves the combined and intermixed use of the

endonasal approach and the external columellar approach to give each individual patient

their optimal immediate and long-term outcome.

I was taught the endonasal delivery flap approach to tip rhinoplasty, and I still

thoroughly enjoy this approach, however, my practice of the endonasal approach has

decreased over the past six to seven years from approximately sixty or seventy percent of

my primary rhinoplasties to about thirty to forty percent. There are specific reasons for

performing more external columellar approach – primarily being recognition of the

need for preventative structural grafting and the ease with which these grafts are placed

through the external columellar approach. It has also become apparent that grafting in

the nasal lobule for prevention of late untoward changes has necessitated the external

columellar approach in increasing numbers of cases.

Not only has evaluating the long term results in tip rhinoplasty affected my choice as

to the external columellar approach or the endonasal approach, but so has the nasal

pyramid. In fact, it is the nasal pyramid that has increased the number of external

columellar approaches I perform more so than maintenance of external nasal valve and

alar cosmetic competency. The traditional cephectomy operation performed for hump

removal has been changed significantly in my hands in order to prevent delayed

occurrence of an “hourglass” visible deformity.1 This inverted V deformity is not

usually due to the dislocation of the upper lateral cartilages from the nasal bones, but is

caused by the inevitable contracture of scar tissue overpowering the strength of the

disarticulated upper lateral cartilages from the dorsal septum. The central cicatricial

inward contraction either results in unilateral or bilateral depressions of the mid nasal

dorsum. In addition, with the upper lateral cartilages falling away from the septum, there

have been more dorsal ridges and irregularities visible over time. Shrink-wrapping of the

skin envelope is particularly evident after five years and highlights dorsal irregularities

that were otherwise not noticed in the first two years of follow-up.2

Recognition of the preexisting condition of the nasal pyramid consisting of a tall,

narrow hump with thin skin and short nasal bones, predisposing to long term inverted V

deformities increases the number of external approaches.

Recognition of a preexisting condition in a lobule has also increased the use of the

external columellar approach with grafting to prevent external nasal valvular collapse and

recurvature of the lower lateral cartilages internally. The weakened, collapsing alar

cartilages create visible deformities of the ala as well as airway obstruction. To prevent

the pyramid deformities that have occurred, I have significantly increased the use of

spreader grafts, which are much easier to suture in place through the external columellar

approach than endonasal.3 Alar strut grafts, which are placed between the vestibular skin

and the alar cartilage, are significantly easier to place from the cephalic direction using

an external columellar incisional approach than from the caudal aspect. These grafts

support the lateral ala and correct the preexisting cephalic malposition of the alar

cartilage.4 This is currently a more recognizable preoperative deformity that lends itself

to late recurvature or collapse of the external nasal valve.5 By placing the alar strut graft,

the airway is maintained and the nasal contour is also maintained.6

Finally, I have recognized that many primary rhinoplasty patients have markedly

asymmetrical alar cartilages from the medial crura to the intermediate crura. Using an

endonasal approach to suture these together can create twists, asymmetries, irregularities

in both the nostril shape as well as the columella itself.

I have most frequently divided the intermediate and medial crura, either symmetrically

or asymmetrically, to create improvements in the projection and symmetry of the lobule.

The Lipsett or modified Lipsett procedure is performed much more easily through an

external columellar incision.7

Therefore, it is the more experienced rhinoplasty surgeon who can learn to recognize

preexisting conditions which are “setups” for pyramid abnormalities. Recognizing

cephalic malposition of the alar cartilages with extremely convex cartilages as one of

these problematic preexisting conditions requires a plan to correct and prevent this.8

Convex nasal cartilages are often best corrected with alar spanning sutures which, again,

are placed much more easily under direct vision through the external columellar

approach.9 Prior to six or seven years ago, I either never or very rarely placed an alar

spanning suture. (This has been a great addition to the narrowing and defining of strong

convex lower lateral cartilages.)

Understanding tip projection and maintaining this is fundamental to the rhinoplasty

operation. This has not changed in the last six to seven years. Nasal tip projection

should not be compromised by endonasal delivery flap approaches. It is easier to

maintain tip projection and place stronger columellar struts, if required, through the

external columellar approach. Both techniques use tip sculpting techniques as well

as strut grafting, and reestablishing medial crural septal relationship to maintain, if not

improve, tip projection.

Handling the Crooked Nose

An asymmetrical or crooked nose that is either C-shaped or angled on a congenital

basis, has been a difficult problem for all rhinoplasty surgeons.10 It is a problem that I

did not correct very satisfactorily early on in my practice. In the past ten to twelve years,

I have increased the use of a variety of osteotomy techniques to correct the angled nose.

I learned the use of double or intermediate osteotomies on the long sloping side of the

nose during my fellowship. However, it has only been within the past seven years that I

have learned to effectively use a transverse root osteotomy via a transcutaneous approach

in order to correct deviations that start from the nasion to the rhinion. More freely using

spreader grafts as well as onlay grafts on top of spreader grafts to camouflage midnasal

dorsal curvatures has assisted in obtaining a much straighter nose postoperatively.

Understanding the use of asymmetrical suture techniques between the septum and upper

lateral cartilages has also assisted in straightening some of these dorsal curvatures.

For curvatures of the caudal septum, which are a problem in terms of recurrence, I

have increased the use of permanent sutures holding the caudal septum to the periosteum

of the anterior nasal spine. I use a 5-0 clear prolene suture. This base septal columellar

suture can be incorporated with a “tongue in groove” technique, if required, in order to

hold the caudal septum between the medial crura and to straighten the columella. I no

longer entirely rely on a temporary 3-0 chromic suture. I have increased the use of

caudal extension grafts for lengthening the short nose and the retruded columella.

In terms of lengthening the short nose, I use a variety of techniques, including the use

of the “cantilever” spreader graft to push the whole lobule in a more caudal, inferiorly

rotated direction.11 Long, extended spreader grafts that extend past the caudal septal

angle are sutured to a strong septal cartilage strut, pushing the lobule inferiorly.12 I have

never performed or favored the complete removal of the septum to modify it ex-vivo and

then replace the septum as a “total” free graft.

Profile-plasty

Over the past ten years, I have recognized the significant assistance of radix grafts to

profile-plasty. A low nasal frontal angle can cause the illusion of a nose that appears to

be all lobule.13 Radix grafts minimize the height reduction of the cartilaginous and bony

dorsum, which is required to maintain its integrity and strength while still giving a

straight profile alignment.14 Maintaining dorsal integrity has been a goal in profile-plasty

over the years but has been particularly emphasized in the last five to six years. I no

longer remove the cartilaginous and bony dorsum en bloc, nor do I remove the

cartilaginous dorsum en bloc with the upper lateral cartilage and septum with the single

cut of an eleven blade. I specifically, individually separate the mucoperichondrium from

the under surface of the upper lateral cartilages where they join the septum. I make a

pocket to maintain the integrity of the mucoperichondrium in nearly all cases. I then

separate the upper lateral cartilages from the septum and maintain the height of the upper

lateral cartilages until I am absolutely certain they need to be reduced. I reduce the

cartilaginous dorsum separately from the bony dorsum and, finally, if necessary, reduce

the height of the upper lateral cartilages. Sometimes I use the upper lateral cartilages by

folding them inward, acting as auto spreader grafts, maintaining mid dorsal strength and

width.

I much more frequently place crushed cartilage grafts placed freely over the rhinion,

bony hump reduced region, and supratip region to improve the dorsal soft tissue

envelope. I rarely count on Alloderm or a cadaveric collagen grafts for persistence in

thickening the overlying fibrous soft tissue envelope. I went through a period of using

Alloderm for this reason and was disappointed in the long term results , particularly after

three to four years. I do not hesitate to use a 1.0 millimeter Gore-Tex® graft for a

blanket graft to camouflage irregularities, particularly in revision rhinoplasty.15 I have

also wrapped more of the radix grafts with temporalis fascia in order to soften the

interface of the cartilage in the nasal frontal angle region. I do not hesitate to use

crushed cartilage as plumper grafts in the tip region as well. I have certainly increased

the use of soft tissue overlay grafts and almost routinely use these when tip grafts are

used, including cap grafts and blocking grafts in thin skinned individuals.16 Any increase

in thickness to the soft tissue envelope, I think is critical to improve long term results.

In summary, with regards to the nasal lobule, the recognition of weak alar side walls

in the preoperative condition is critical to improving long-term results. This may be

merely that the alar margin is a bit weak.17 In my practice, placement of alar rim grafts

has increased ten-fold in the past three to four years. These are small grafts placed near

the end of the operation in a small defined pocket along the alar margin, giving a little

more strength and straightening to an otherwise weak alar margin.18 If the alar cartilages

are cephalically malpositioned or there is a tendency for recurvatuare, even in the preop

condition, the placement of alar strut grafts is planned. These are different than alar

batten grafts placed on top of the alar cartilages for additional support to the alar

cartilage. These grafts are actually struts themselves, merely preventing the weak alar

cartilages from falling inward, creating a recurvatuare phenomenon and alar valve

collapse. Finally, recognizing that double dome suturing techniques do not by

themselves solve the problem of adequately narrowing the nasal supratip lobule in

patients with convex, strong alar cartilages. In addition to potentially placing alar strut

grafts, one must use alar spanning sutures to bring these convex portions of the cartilage

inward, maintaining structural support to the alar cartilage itself. No longer should one

morselize or otherwise weaken the lateral alar cartilage. These have been a great addition

to lobuloplasty in the past four years.

Conclusion

The evolution of my rhinoplasty practice over the past six to ten years has been dramatic.

The increasing use of small grafts, if not structural grafts, to maintain or prevent late

problems has been paramount to improved results that stand the test of time. These grafts

are easier to place through the external columellar incision, and I have increased the use

of my “open approach” approximately twenty percent. However, I still thoroughly enjoy

the endonasal approach to primary rhinoplasty when the patient’s condition warrants.

This makes for a very straightforward and fairly short operation achieving maximum

aesthetic results with minimum postoperative down time for the patient. I believe the

mature (experienced) rhinoplasty surgeon needs to be able to perform this operation via

either the external columellar approach or an endonasal approach to maximally serve

his/her entire patient population. It is unfortunate if a young rhinoplasty surgeon is not

exposed to the beauty of the endonasal operation. I will continue to perform this

approach and develop ways to increase grafting and maintain support in the mid nasal

vault and alar sidewalls while still doing endonasal approach rhinoplasty.

Figure 1 Patient with late development of “hourglass deformity” or “inverted V”.

Figure 2 Shrink wrapping of dorsal skin showing irregularities.

Figure 3 Strut grafts in place via external columellar approach.

Figure 4 Patient with cephalic malposition of alar cartilages.

Figure 5 Patient with late recurvature and partial collapsed lateral ala and

external nasal valve

Figure 6 Placement of alar strut graft between lateral crus and vestibular skin.

Figure 7 Modified Lipsett maneuver used to correct medial crural discrepancies.

Figure 8 Patient with strong convex alar cartilage.

Figure 9 Placement of ala spanning sutures.

Figure 10 Patient with congenital crooked angulated nose (pre and postop)

Figure 11 “Extended” spreader grafts used as a cantilever to lengthen the short nose.

Figure 12 Pre & postop of patient with short nose.

Figure 13 Patient with low or deep nasofrontal angle.

Figure 14 Pre & postop patient result using radix graft.

Figure 15 Pre & postop patieint with 1.0 mm Gore-Tex® .

Figure 16 Tip grafted patient with soft tissue overlay.

Figure 17 Patient with “weak” alar margin.

Figure 18 Placement of alar rim graft.