Facial Cosmetic Surgery
Facial cosmetic surgery in this section refers to soft tissue procedures of the face. In reality, modern facial cosmetic surgery includes procedures that enhance the appearance of the skeleton (orthognathic surgery), esthetic dental implantology and prosthetic rehabilitation, dermatologic procedures (skin resurfacing), hair restoration, and facial plastic surgery (Figure 13-1). Only oral and maxillofacial surgeons have the opportunity to provide all these services.
Figure 13-1 The full scope of facial cosmetic surgery encompasses three disciplines: orthognathic surgery, dental implantology/prosthetics, and facial plastic surgery with cosmetic dermatology. (From Bagheri S, Bell B, Khan HA: Current therapy in oral and maxillofacial surgery, St. Louis, 2012, Saunders.)
As in most cosmetic procedures, the vast majority of advances arise from the teaching of surgical skill sets to younger surgeons through operative training, textbooks, lectures, and symposia. The difficulty of developing randomized or prospective cohort studies and multicenter analysis for cosmetic procedures contributes to the progression via traditional (non-research-based) modes of teaching. Cosmetic surgery is unique among surgical specialties due to changing trends and racial and regional ethnic preferences that drive the patient’s desires regarding what is considered an esthetic result.
Facial cosmetic surgery has gained tremendous popularity in the past decade. One reason for this rise in interest is the consumer’s increased accessibility to information through television, the Internet, and other media sources. Also, the development of safe and effective surgical techniques, with reduced “downtime” and long-lasting, natural-appearing results, has popularized this field. Facial cosmetic surgeons must intimately understand facial anatomy, in addition to the anatomy and physiology of the aging process. Although some patients seek to rejuvenate their appearance to “turn back” the hands of time, others are interested in altering their appearance to a more desirable social norm.
In each area of the face, several different surgical techniques have been developed to improve the appearance; each of these techniques has its own merits. It is the intent of this section to introduce readers to the concepts responsible for the evolution of facial cosmetic surgery techniques. Teaching cases involving facial cosmetic surgery include face-lift surgery, endoscopic brow lift, blepharoplasty, rhinoplasty, and genioplasty, in addition to injection of Botox and facial fillers. Each section is designed to emphasize the key points of the examination, contrasting the presenting deformity with the ideal, youthful norms. The rationale for surgical techniques to improve the outcome and achieve lasting results based on facial anatomy and the process of facial aging is described. Ultimately, the techniques used by facial cosmetic surgeons are based on the surgeon’s preference and training and the clinical situation.
Both genetic and extrinsic factors contribute to the aging process. The genetic factors are fixed. Extrinsic factors can be altered and include excess sun damage, smoking, a healthy diet, and exercise. Rejuvenation of the face should be tailored to the individual by improving the patient’s overall health, addressing the health of the skin, and possibly using adjunctive surgical procedures to enhance beauty. For smokers, the single most effective method of improving one’s health (including the skin) is to stop smoking. For “sun lovers,” it is old news: excessive sun exposure damages (burns and dries out) the skin. The goal of facial cosmetic surgery is to improve and refresh the appearance of the face without any signs of obvious surgical intervention after healing is complete.
Oral and maxillofacial surgeons are uniquely trained to recognize and manage facial deformities at all levels. Facial rejuvenation and cosmetic surgery has been described as analogous to building a house. First, the foundation must be established (skeletal surgery). Next, the framing and walls must be built (soft tissue surgery). Finally, the paint must be applied (skin resurfacing). With proper understanding and training, facial cosmetic surgery can be easily incorporated into the oral and maxillofacial surgery (OMFS) practice.
Botulinum Toxin A (Botox) Injection for Facial Rejuvenation
A 44-year-old Caucasian woman presents to your office for consultation regarding the wrinkles on her forehead. (The majority of patients seeking facial rejuvenation are females; however, interest in these procedures is growing in the male population.)
During an orthognathic surgery consultation for her daughter several months ago, the patient noticed the Botox pamphlets in the waiting room at your office (unlike other branches of OMFS, a busy cosmetic surgery practice is usually heavily dependent on marketing and advertisement). The patient states that “these lines” have recently appeared on her forehead and that she is tired of looking as if she is “scowling” or “frowning.” Her husband has mentioned to her that the wrinkles make her appear “angry.” Several of her friends have had satisfactory results with Botox injections for glabellar and periorbital lines. She has many questions regarding the safety and outcome of Botox injections for elimination of wrinkles.
The patient does not have any known medical conditions. Specifically, she has no known history of neuromuscular diseases, including myasthenia gravis, amyotrophic lateral sclerosis, multiple sclerosis, Eaton-Lambert syndrome, or other motor neuron–related disorders (despite the absence of specific studies, Botox should be used cautiously in individuals with neuromuscular disorders due to potential exacerbation of any preexisting conditions). There is no significant family history of neuromuscular disorders.
The patient currently is not taking any aminoglycoside antibiotic or other medications that could interfere with neuromuscular transmission. (It is recommended that Botox injections be delayed or avoided in patients taking aminoglycosides.) She is not taking aspirin, a nonsteroidal antiinflammatory drug (NSAID), or other medication that can interfere with coagulation or platelet function (such drugs increase the risk of hematoma formation and bruising). She smokes one-half pack of cigarettes per day (smoking is not a contraindication to Botox injection).
There is no history of allergies to human albumin or of any previous adverse reactions to Botox. (Botox manufactured after 1997 has a lower albumin concentration and therefore a presumably lower risk of clinical antigenicity.) The patient currently is not pregnant or lactating. (Botox is contraindicated during nursing or pregnancy; it is classified by the U.S. Food and Drug Administration [FDA] as Pregnancy Category C, meaning that its safety profile during pregnancy has not been studied. It is unknown whether the toxin can cross the placenta or is excreted during lactation. However, the localized application of the drug would suggest the safety of application during pregnancy or nursing).
General. The patient is a thin, athletic, well-dressed female. She wears an extensive amount of makeup, which masks some of her facial features of aging. She wears her hair in a style that reduces the visibility of the forehead lines (subtle observations about appearance may be the key to successful patient rapport).
Maxillofacial exam. There are no pustules or signs of active dermatologic infections or pathology in the facial region (injections are contraindicated if an active infection exists at the injection site). There is no marked facial asymmetry or hypertrophic facial scarring (thick skin or a susceptibility to hypertrophic scars may be a relative contraindication to injections). No significant eyebrow ptosis is noted. (This is important for injection around the eyes or the forehead. Impairing the functioning of the frontalis can also lower the brow position from unopposed muscle action, resulting in an unappealing outcome. Similarly, large amounts of Botox injected around the eye can diffuse toward the levator palpebrae muscle, causing impaired eyelid closure. The degree of preoperative ptosis can be documented for postoperative comparison.)
Several prominent horizontal forehead wrinkles (due to frontalis muscle action) are present at rest (Figure 13-2, A) and are accentuated with animation (Figure 13-2, B). Multiple hyperdynamic rhytids (lines on the face) are seen lateral to the eye and are most pronounced on animation (orbicularis oculi region, also known as “crow’s feet”; Figure 13-3, C). At rest, fine vertical glabellar furrows are present, and upon animation and frowning, the glabella muscle bulge becomes significantly prominent (the corrugator muscle is responsible for the vertical glabellar furrows, and the procerus muscle is responsible for the horizontal glabellar furrows). A glabellar spread test reveals that the glabellar lines are substantially decreased when physically manipulated or spread apart. (This is a good indication that the muscle and its overlying soft tissue are the etiology of the lines. During the physical exam, it is important to distinguish between dynamic and static wrinkles. Botox decreases dynamic wrinkles because of its effect on muscles. Static wrinkles may be treated using soft tissue fillers to decrease skin laxity at rest.)
Figure 13-2 A, Forehead wrinkles secondary to frontalis muscle functioning. B, Forehead lines accentuated during frontalis function. C, Hyperdynamic periorbital lines (crow’s feet) accentuated with animation.
Figure 13-3 A, One month postoperative view at rest, showing significant reduction of horizontal forehead lines. B, One month postoperative view upon brow elevation, showing significant reduction of horizontal forehead lines with animation. C, One month postoperative view of the lateral periorbital lines (crow’s feet) seen during animation.
Standard facial photographic documentation of the areas to be treated is recommended (but not essential) for Botox injection. Comparisons of preinjection and postinjection photographs may be important for future dosing and for surgeon education toward optimal results.
No routine laboratory tests are indicated. Patients taking large doses of anticoagulants are at risk for small hematoma formation at the injection site. The treating surgeon should inquire about any coagulation studies to assess the risk and to educate the patient about this potential temporary yet undesired effect.
Multiple areas of hyperfunctioning facial muscles and signs of aging are present involving the periorbital, glabellar, and horizontal forehead regions. The patient desires injection of Botox for effacement of the wrinkles associated with the periorbital and forehead regions. (Although there may be many findings amendable to cosmetic surgery, the assessment and treatment are dictated by the patient’s desires.)
After a complete discussion of the procedure, risks, and alternatives, the patient signed the informed consent (which addressed all the complications listed later). One hundred units of Botulinum Toxin A was reconstituted with 3.3 ml of unpreserved normal saline. (According to a study by Alam and colleagues in 2002, the use of preservative-containing normal saline is less painful than preservative-free saline. However, this is not in accordance with the manufacturer’s recommendations.) Botox is available in a sealed vacuum container that allows for easy reconstitution with saline. The resulting solution provides 3 units per 0.1 ml, or 15 units per 0.5 ml. Botox should be reconstituted gently (shaking and trauma to the toxin can diminish its potency) with a 21-gauge needle and then gently drawn into a tuberculin syringe. The syringe can be used with a short 30-gauge needle.
The patient was seated upright, close to a 60-degree position. After the injection sites had been prepared with alcohol, the patient was asked to frown (or lower the eyebrows) to highlight the regions of maximum muscular contraction. Six injection sites were identified to inject the frontalis muscle. To minimize the chance for blepharoptosis, the injections were performed at least 1 cm above both the central eyebrow and the supraorbital ridge. (It is important to avoid injections on the forehead lateral to the lateral canthus, to prevent inhibition of temporalis function. The goal of forehead injections is not to completely eliminate the frontalis muscle action, because this can cause undesirable brow ptosis.) Ice packs were applied immediately prior to injection to blunt the pain response from needle injection. The needle was inserted into the belly of the muscle, aspiration was performed, and Botox was then slowly injected. After the injections no manipulation was performed, and an ice pack was allowed to rest on the area (manipulation can enhance diffusion into other muscles, affecting the levator palpebrae superioris and causing blepharoptosis, especially with injections near the eyelid). Attention was then turned to the orbicularis oculi region. After the area had been prepared with alcohol, 9 units total was injected into three sites, on each side just below the skin (to minimize diffusion in this area). A total of 36 units was used for the forehead and crow’s feet regions (18 units in the forehead and 18 units total for both eyes).
Ice was allowed to rest on the injection sites for as long as the patient tolerated. The patient was instructed to remain upright for at least 4 hours and was allowed to apply makeup 4 hours after injection (to minimize manipulation and thus diffusion of the toxin). She was allowed to resume exercise the next day. She was instructed to expect a noticeable effect in 3 to 4 days, with maximum benefit in 30 days (Figure 13-3). Follow-up was scheduled in 1 week. The areas can be reinjected after a minimum of 3 months has elapsed (earlier injections can increase the chance of antibodies developing).
• Blepharoptosis: The reported occurrence is 1% to 2% of periorbital injections. This can be treated with an α2-adrenergic agonist (apraclonidine 0.5% eye drops, to be used 30 minutes before social situations), which stimulates Mueller’s muscle, resulting in hours of transient lid opening.
• Formation of neutralizing antibodies: This has been reported to occur with repeat injections within 1 month of the previous injections; it also was reported with doses greater than 100 units per treatment session. This has not been reported for the cosmetic use of Botox; however, it is recommended that a period of at least 3 months elapse between injections.
Botox is a formulation of botulinum toxin A purified neurotoxin complex, produced from fermentation of the gram-positive spore-forming bacteria Clostridium botulinum type A. When injected into striated muscle, it produces a dose-dependent local muscle weakness by preventing the release of acetylcholine from the nerve terminal at the neuromuscular junction (chemical deinnervation). The action involves a four-step process that culminates with the cleavage of the 25kD synaptosome-associated protein (SNAP), which is essential for the exocytosis of acetylcholine. The paralytic effect is temporary, because there is a gradual recovery of the activity of the nerve terminal over 3 to 6 months. The unit of measurement for Botox is derived from work with mice. One unit of Botox is the lethal dose in 50% of mice (LD50). The LD50 in humans is 2,500 to 3,000 units (40 units/kg). Dosing for the clinical effects of Botox can vary among individuals. Thicker muscles and male patients often require more Botox units to achieve the desired effect.
Unopened vials of Botox can be stored for 24 months in a refrigerator (2° to 8°C). Opinions vary regarding its shelf life, once reconstituted, beyond the manufacturer’s recommendation of only 4 hours. Studies have suggested no clinical difference for up to 6 weeks after reconstitution, but others have noticed diminished potency beyond 48 hours.
As of this writing, FDA approval for the use of Botox includes treatments for dystonia, torticollis, blepharospasm, strabismus, wrinkles caused by the procerus and corrugator muscles (glabellar region), and severe primary axillary hyperhidrosis in patients younger than 65 years of age. However, common off-label uses are numerous and include hyperhidrosis for the palms, Frey’s syndrome, migraine headaches, myofascial pain, bruxism, masseter hypertrophy, chronic temporomandibular dislocation, limb spasticity, and platysmal banding, among many others.
In the oral and maxillofacial surgery office, injections are commonly administered in the upper face region, such as the glabella, lateral canthal lines (crow’s feet), and forehead (frontalis). Selective brow raising techniques can be done. By injecting the lateral orbicularis muscle without injecting the frontalis in select areas, the brow peak can rise as a result of unopposed frontalis muscle action. Noncosmetic injections for trigger pain regions of the temporalis and masseter muscle also can be performed. Lower face injections to treat “lipstick lines” should be reserved for experienced surgeons and may cause oral incompetence. Fillers, such as a non-animal-sourced hyaluronic acid (Restylane [Medicis Pharmaceutical Corporation, Bridgewater New Jersey]), can be used concomitantly with Botox to augment static wrinkles. Patient satisfaction has been shown to be increased with the use of these two techniques.
Alam, M, Dover, JS, Arndt, KA. Pain associated with injection of botulinum A exotoxin reconstituted using isotonic sodium chloride with and without preservative: a double-blind, randomized controlled trial. Arch Dermatol. 2002; 138(4):510–514.
Carruthers, J, Carruthers, A. A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane) alone in severe glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides with a hyaluronic acid derivative compared with the derivative and BTX-A. Dermatol Surg. 2003; 29:802–809.
Hexsel, DM, De Almeida, AT, Rutowitsch, M, et al. Multicenter, double-blind study of the efficacy of injections with botulinum toxin type A reconstituted up to six consecutive weeks before application. Dermatol Surg. 2003; 29(5):523–529.
Solish, N, Benohanian, A, Kowalski, JW. Canadian Dermatology Study Group on Health-Related Quality of Life in Primary Axillary Hyperhidrosis: prospective open-label study of botulinum toxin type A in patients with axillary hyperhidrosis—effects on functional impairment and quality of life. Dermatol Surg. 2005; 31(4):405–413.
A 30-year-old, healthy Caucasian woman presents for consultation for upper lip augmentation. She complains that her upper lip is “thin” and does not match her lower lip. She desires a “mild” augmentation of her upper lip and specifically does not want to have an excessively “pouty” upper lip.
The patient has no previous history of facial filler for soft tissue augmentation. She has recently gone through a divorce and desires to improve her looks for the new year. She appears to have realistic expectations and is well educated, via the Internet, about the different products available on the market. She has had previous breast augmentation surgery, with satisfactory results.
Maxillofacial. The patient does not have lymphadenopathy. Her facial skin is without any lesions, and her oral mucous membranes are moist. Oral hygiene is excellent. Nasal and maxillary dental midlines are aligned.
Lips. The lips are symmetrical (Figure 13-4). The upper lip to lower lip height ratio is about 1 : 2 (in general, an aesthetic upper lip is one third of the total lip mass, and the lower lip represents two thirds of the total lip height). The upper lip is relatively deficient in volume compared with the lower lip. Cupid’s bow and the vermillion border are well defined, with good profile projection. Four millimeters of central incisors is visible at rest (normal range is 3 to 4 mm for females and 2 to 3 mm for males), with no gingival show on smiling (no “gummy” smile). She does not exhibit lip incompetence. The nasolabial angle is within normal limits (100 degrees ± 10 degrees).
Normal esthetic parameters for the lips are differently defined among persons of different races and cultures; therefore, “normal” parameters are not well established. As in any cosmetic procedure, the patient’s desires and expectations, along with fashionable trends emphasized by the media and celebrities, play a major role in the patient’s and surgeon’s decisions regarding cosmetic intervention.
Lab tests are not indicated unless there is a known history of coagulopathies (increased risk of hematoma, bruising, and erythema at the injection site). Unlike collagen, hyaluronic acid is identical among species, making it highly biocompatible and thus eliminating the need for allergy testing (see Complications).
Restylane is a stabilized, lower-molecular-weight, partially cross-linked hyaluronic acid that has been approved by the U.S. Food and Drug Administration (FDA) for soft tissue augmentation. It is created via bacterial fermentation from streptococcal species. This material has been used in Europe and Canada since 1996 and received FDA approval for use in the United States in 2003. Hylaform Gel is a hyaluronic acid extract derived from rooster combs.
Bilateral infraorbital nerve blocks are given to achieve upper lip anesthesia without local infiltration in the areas to be augmented to avoid temporary tissue distortion secondary to the injection. The white roll is augmented on the upper lip, starting at the midline and following the contour of Cupid’s bow to enhance both definition and projection. The material is injected in a linear threading fashion as the needle is withdrawn away from the midline via two or three injection sites. The upper lips are intermittently massaged to achieve uniform distribution of the filler. The contralateral side is injected in a similar fashion. The body of the lip is also injected in a similar fashion to achieve volume enhancement of the lips. For the current patient, a total of one syringe was used for the upper lip (Figure 13-5).
Many surgeons actively involve the patient by allowing her to occasionally evaluate the lips in a mirror to achieve the desired effect and to give the patient a sense of participation in the treatment.
Other materials and techniques used for lip augmentation include AlloDerm (cadaveric acellular dermal collagen framework), polytetrafluoroethylene, autologous fat transfer/injection (harvested from periumbilical right medial thigh fat), injectable collagen, or a strip of superficial musculoaponeurotic system (SMAS) when concurrent facelift procedures are performed.
The ideal facial augmentation material should be inert, biocompatible, and safe and should remain stable over time. Bovine collagen has dominated the facial filler market until recently. The main concern associated with it is the risk of severe allergy, requiring allergy skin testing before injection. The use of autologous collagen harvested from the patient’s own skin eliminated the need for allergy testing, but it needs to be harvested, which involves associated morbidity and limited supply. Autologous fat also eliminates the need for skin testing, but it also involves harvesting. This may be desirable if simultaneous liposuction is being performed. Dermalogen (Collagenesis; Beverly, Massachusetts) is human collagen prepared from human donor tissue processed from cadavers. This material undergoes extensive screening for infectious agents and is irradiated before use. Skin testing is not required by the FDA.
Several formulations for hyaluronic acid are available for injection into soft tissue, but not all are FDA approved. Olenius conducted the first clinical study to evaluate biodegradable implants. He evaluated 113 subjects after injection with partially cross-linked hyaluronic acid and reported no allergic reactions and infrequent side effects; these were limited to localized erythema and swelling related to superficial placement of the material, small hematoma formation, and lumpiness secondary to uneven injection. In 2001, Lowe and associates studied 709 patients injected with hyaluronic acid preparations. They reported a 0.42% incidence of delayed inflammatory skin reactions that started about 8 weeks postinjection. A review of worldwide data on 144,000 patients treated in 1999 indicated that the major reaction to injectable hyaluronic acid was localized hypersensitivity, occurring in approximately 1 of every 1,400 patients treated. This study concluded that hypersensitivity to non-animal-source hyaluronic acid gel is the major adverse event and is most likely secondary to impurities of bacterial fermentation. More recent data indicate that the incidence of hypersensitivity appears to be declining after the introduction of a more purified hyaluronic acid raw material.
Knowledge of vascular anatomy is essential. Case reports have noted that intraarterial injection of hyaluronic acid can cause localized skin changes and autologous fat embolization, resulting in ocular and cerebral ischemia.
A common question asked by patients is the duration of the augmentation. In the study by Olenius, injection of partially cross-linked hyaluronic acid demonstrated the greatest degree of effectiveness at 2 weeks (98%), with subsequent decline at 3 months (82%), 6 months (69%), and 1 year (66%). Although the effects of this filler are not permanent, repeat injections may require smaller amounts of filler to achieve similar results.
It is essential that surgeons do not apply a single method of augmentation for every patient who presents to the office. Accurate diagnosis of the facial deformity or the desired effect is the key to satisfactory outcomes. A thorough knowledge of multiple techniques, in addition to the safety profiles of the existing materials and their clinical effects, is essential for successful soft tissue augmentation.
The patient works in the beauty industry but has been aware of the shape of her nose since college. Several years ago, she noticed the prominence of her nasal dorsum and the bulky mid dorsal area when she looked in the mirror. In addition, she complains of difficulty breathing through her right nostril. She reports breathing better through the left nostril, and when she pulls her right cheek inferiorly and laterally, she experiences improved airflow through the right nostril (positive Cottle’s sign).
The patient has no previous history of septoplasty, cosmetic rhinoplasty, or nasal trauma. (Previous nasal surgery is particularly important, because the anatomy may be altered. If the septal cartilage has been previously harvested or adjusted and there is a need for cartilage grafting, ear or rib cartilage can be used). She denies any seasonal or drug allergies (it is important to note symptoms of allergic rhinitis or recent upper respiratory tract infections). There is no history of psychiatric disorders or treatment (patients with certain psychiatric disorders may not be candidates for elective cosmetic procedures). There is no history of smoking or cocaine or other drug use (cocaine-induced vasoconstriction compromises wound healing and increases the risk of septal perforation). She also has no history of granulomatous or autoimmune disorders (e.g., Wegener granulomatosis, which can affect the nasal mucosa) or of epistaxis (a prior history of unexplained epistaxis should be investigated for blood dyscrasias, such as von Willebrand disease).
Examination of the nose for cosmetic surgery has to include both cosmetic and functional factors. Cosmetic evaluation should encompass the entire face, but for planning purposes, the nose can be examined in five regions:
Each region is evaluated in three dimensions. The functional aspects of the nose (mainly breathing) require a careful endonasal speculum examination. Correction of cosmetic parameters may cause or exacerbate nasal function (e.g., narrowing the nose may compromise breathing).
Skin. The skin meets the criteria of Fitzpatrick type II with no evidence of acne or excessive sebaceous secretions. The skin and soft tissue envelope have adequate thickness over the dorsum and tip (Figure 13-6).
Dorsum. There is a prominent dorsal hump on the profile view (Figure 13-7). The mid dorsum is rectangular in shape on the frontal view. The nasal dorsum is wide but symmetrical.
Speculum exam. There is linear deviation of the quadrangular cartilage (nasal septum) to the right and partial blockage of the right internal nasal valve (the angle formed by the nasal septum and upper lateral cartilage). There is compensatory inferior turbinate hypertrophy on the left, with mild erythema of the nasal mucosa and turbinates.
|Anatomic Region||Main Characteristics|
|Dorsum||Width, size, symmetry|
|Tip||Volume, projection, shape, definition, rotation, width|
|Nasal base||Alar base shape, nostril size, columellar anatomy, alar width, symmetry|
|Turbinates||Size, obstruction of airflow, inflammation|
From Bagheri SC, Bell RB, Khan HA (eds): Current therapy in oral and maxillofacial surgery, St Louis, 2012, Saunders.
Preoperative and serial postoperative photoimaging is mandatory for cosmetic procedures. Standard photography for cosmetic rhinoplasty includes frontal, right and left lateral, right and left oblique, and basal (“worm’s eye”) views. Photographs should be standardized to allow optimal preoperative and postoperative comparisons.
Patient desires cosmetic rhinoplasty: prominent dorsal hump on profile; wide nasal dorsum on frontal view (“boxy dorsum”); bulbous tip as seen on the frontal view, with good projection; deviated septum with compromised right nasal valve function.
Treatment is dependent not only on the physical findings (diagnosis) but, more important, also on the patient’s desires and expectations. Many of the fundamental principles of cosmetic rhinoplasty have evolved since the popularization of this procedure in the past 40 years. Initially rhinoplasty was primarily performed as a reductive procedure, focused on removal of the dorsum and cartilage excision. More recently cartilage grafting and advanced suturing techniques have caused a paradigm shift toward tissue preservation and anatomic form. The concept of “balanced” rhinoplasty refers to alterations of nasal anatomy by reduction, augmentation, or alteration to achieve the anatomic harmony between the radix, dorsum, tip, and alar base. The surgical access to the nasal structures has also seen the dramatic popularization of the open approach.
The current patient complains of a large nose and difficulty breathing through the right nostril. Treatment should address both the esthetic and functional disturbances. Cosmetic alterations frequently exacerbate functional parameters. The surgical plan must be developed preoperatively, based on the patient’s function and cosmetic desires and needs.
The surgical approach (endonasal versus open rhinoplasty) depends on the complexity of the case and the experience and preference of the surgeon. Incisions for endonasal rhinoplasty include the following (Figure 13-8):
Standard incisions for approaching the nasal septum include the transfixion incision (through the membranous septum) and the Killian incision (incision over the cartilaginous septum). Most simple rhinoplasties can be done via an endonasal approach. However, if complex tip work or spreader grafts are required, an open transcollumellar incision allows greater access and visibility than the cartilage delivery approach (Figure 13-9). The scar from this incision is usually not visible several months after the procedure.
For any rhinoplasty surgery, a treatment plan should be outlined to address the patient’s desires within the confines of the surgeon’s ability to achieve the outcome and without compromise of nasal function. The following surgical plan was created for the current patient.
Under general anesthesia, lidocaine with epinephrine was injected along the nasal septum, columella, dorsum, and nostril areas, and adequate time was given for vasoconstriction (some surgeons limit the amount of subcutaneous local anesthetic injected to minimize tissue distortion, for improved intraoperative assessment). A septoplasty and septal cartilage harvest were performed via a left hemitransfixion incision (a minimum 1-cm strut of dorsal and caudal cartilage should be left intact for adequate support), followed by submucosal resection with lateral displacement of the right inferior turbinate. Careful attention was given to maintaining adequate dorsal and columellar cartilage, to avoid a saddle nose deformity. An open rhinoplasty (inverted V transcolumellar with infracartilaginous incisions) was performed, with subsequent resection of 4 mm of the cephalic margin of the lower lateral cartilages (cephalic trim or volumetric reduction). Domal equalization and creation sutures were used to provide tip definition (some surgeons may elect to split the domes). Reduction of the bony dorsum was performed using a rasp, followed by excision of the cartilaginous dorsum using fine scissors. Strut and shield grafts were not used in this patient (although some authors suggest that strut and shield grafts be used in most patients). The nasal tip was supported by suturing the medial crura of the lower lateral cartilages to the nasal septum (a columellar strut can be used to achieve greater tip projection). The septum was disarticulated from the upper lateral cartilages bilaterally, and a spreader graft was placed (to increase the internal nasal valve). Finally, low-to-high lateral nasal osteotomies were performed, and the nasal complex was fractured in to close the open “book deformity” and address the width of the dorsum. Figure 13-10 shows the postoperative patient profile.
Cosmetic rhinoplasty is a difficult procedure to master. It is imperative to recognize complications early and not to ignore a potentially correctable finding. Management of a dissatisfied patient can be challenging, but foresight, honesty, and a caring approach frequently aid in resolving an unsatisfactory outcome. These unsatisfactory outcomes may include a polly beak, saddle nose, open roof deformity, undercorrection, dorsal irregularities, nasal tip deformities, or asymmetrical dorsum/tip. An overall revision rhinoplasty rate of 5% to 15% has been reported. Other reported complications include hemorrhage (1% to 4%), infection (0% to 3%), septal perforation (0.1%), skin sloughing (rare), and nasal obstruction (1% to 10%).
Patients undergoing open rhinoplasty should be informed about the postoperative anesthesia or profound hypoesthesia of the nasal tip. This is usually temporary but can take 6 months to 1 year to resolve.
Primary cosmetic rhinoplasty is the surgical manipulation of a previously unoperated nose for esthetic enhancement. A history of septoplasty in the absence of any cosmetic nasal alterations may change the treatment plan related to septal harvest, yet the procedure remains a primary cosmetic rhinoplasty. This is distinguished from revision and reconstructive rhinoplasty. In a revision procedure, the surgeon attempts to correct or further modify a previously operated nose. A revision procedure may be indicated if the patient and surgeon agree that the expected or planned results were not obtained from the primary procedure or if results are compromised due to complications. This is further distinguished from a repeat, or “re-do,” rhinoplasty, in which a patient presents after a primary rhinoplasty requesting changes from a previously satisfactory result. Reconstructive rhinoplasty is the esthetic and/or functional enhancement of a nose that is altered by trauma, pathology, or ablative tumor surgery.
The most important factor in a successful cosmetic rhinoplasty is patient selection. Equally important is the surgeon’s ability to recognize his or her limitations in meeting the patient’s cosmetic demands. The nose needs to be examined in conjunction with the rest of the face, and considerable attention needs to be given to the patient’s ethnic background. Most normal anatomic nasal measurements in the literature are for Caucasians; therefore, treatment planning must be done with caution. A systematic approach to analyzing the nose, both as a component of the face and as an independent entity, is essential. For example, a prominent nose may be accentuated by a hypoplastic mandible or chin, and the patient may benefit from an advancement genioplasty or alloplastic augmentation. Additionally, both cosmetic and functional aspects need to be addressed and anticipated. It is imperative for the surgeon to realize that an optimal cosmetic outcome may compromise nasal function. A good example is internal nasal valve compromise secondary to excessive nasal dorsum narrowing. Additional procedures may be considered, such as spreader grafts (cartilaginous graft between the nasal septum and upper lateral cartilage) to widen the nasal valve area.
Ultimately a successful cosmetic rhinoplasty requires that the patient clearly communicate his or her desires and expectations for surgery. The surgeon must take the time to understand and recognize unrealistic requests, ambiguity, and contradictions in the patient’s desires. Subsequently, the surgeon must have a complete grasp of the surgical maneuvers at his or her disposal and be able to translate them into an custom operation that meets the patient’s requests. It is essential that the surgeon recognize that each surgical intervention has a standard range of applications and an error margin that can cause deviations from the planned procedure. The more complex the set of interventions, the greater the margin of error. The current principles of rhinoplasty emphasize adherence to minor but key changes that result in more predictable and lasting outcomes. When possible, surgeons should evaluate their results beyond the first 6 to 12 months. Although to a lesser extent, the nose continues to change beyond this period. The stability of the cosmetic result depends on the degree of cartilaginous, ligamentous, bony, and soft tissue disruption and on surgically designed structural modifications. Long-term results can be difficult to decipher, not only due to difficulty in follow-up, but also because the nose continues to age, along with the other facial structures
A 28-year-old male presents for a consultation regarding his symptomatic third molars. There have been three episodes of pericoronitis requiring antiobiotic treatment in the past year. He also complains of difficulty breathing through the left side of his nose.
The patient reports no history of prior nasal surgery. However, his nose was forcefully struck in a sporting accident at age 24 (prior nasal injury is a risk factor for deviated septum). No surgical treatment was provided at that time. Subsequent to that injury, he has not been able to breathe through his left nostril. (Nasal obstruction due to septum deviation can occur due to birth trauma or, more likely, secondary to developmental changes or, as in the current patient, facial trauma).
No significant medical illness. The patient denies a history of abuse of cocaine or other nasally inhaled substances, such as nose drops or sprays (rhinitis medicamentosa can cause postoperative septal perforation due to chronic mucosal vasoconstriction). He does not have symptoms of nasal allergy (seasonal, due to pollens; perennial, due inhaled or ingested irritants, infectious agents or a combination of these) or vasomotor rhinitis (nasal congestion, hypersecretion, sneezing due to parasympathetic system instability). Such conditions should be diagnosed and controlled or resolved prior to nasal septal surgery. There is no history of Wegener granulomatosis (small and medial-sized vasculitis that can affect the nose, causing pain, epistaxis, and nasal deformities due to septal perforation). The patient denies tobacco use. (Tobacco smoke is irritating to the nasal mucosa, and nicotine causes generalized vasoconstriction. Smoking after a nasal—or any—operation seriously interferes with the healing process and may become a critical factor in wound breakdown and/or the development of an infection).
The nose is examined in conjunction with the other facial structures for both its functional and cosmetic aspects (see the section Rhinoplasty in this chapter). Physical examination should include inspection and direct visualization of the septum, turbinates, nasal mucosa, nasal passages, nasal valve, radix, dorsum, columella and anterior nasal spine. (Occasionally a tumor occurs in the nasal passages, and an area showing changes suspicious for neoplasia should be biopsied.) The examination of the current patient proceeded as follows.
External nasal examination. The nasal bones are stable and symmetric. The tip and septum are deviated to the left. The anterior nasal spine is palpated and appears coincident with the facial midline, but the cartilaginous caudal septum is deviated to the left. The bony radix and dorsum are in the midline. The external cartilaginous caudal nasal structures (dorsum, tip, columella) show only mild deviation to the left (significant septal deviation is not always associated with a cosmetic nasal deformity of the columella, dorsum, or tip).
Rhinoscopy (examination of the nose with a speculum). Nasal mucosa is nonerythematous with normal moisture and absence of polypoid tissue (erythema, excessive secretions and polyps would be indicative of allergic rhinitis). The quadrangular cartilage and bony septum are significantly deviated to the left, closing the nasal valve angle with nearly complete blockage of the airway, prominent midseptal bowing, and contact of the septum with the left inferior turbinate. The septum is also deviated inferiorly to the left. Both of the inferior turbinates are enlarged, with the right larger (compensatory turbinate hypertrophy) than the left. The left nasal valve is obstructed by this deviation.
Endoscopic nasal examination. After spraying the nose with oxymetazoline (α1 agonist and partial α2 agonist), endoscopic examination confirms the presence of right inferior turbinate hypertrophy and leftward deviation of the septum with no visible mucosal pathology. (Endoscopy is not necessary to diagnose and treat a deviated septum. However, it can be helpful in the evaluation of the posterior nasal structures; that is, the superior nasal passages, the paranasal sinus meatuses, and the posterior nasal choanae, especially in the absence of CT examination).
Cottle’s test (negative). This test did not improve airflow in the current patient. The test is done to evaluate airflow due to nasal valve obstruction or compromise. The contralateral nostril is gently closed by the examiner, and the ipsilateral cheek is pulled laterally to open the nasal valve. If airflow is improved by this maneuver, the nasal valve deficiency is potentially contributing to airflow obstruction. (This is a very unreliable test that produces many false positives; that is, lateral retraction of the cheek improves the airway in many patients who only have temporary nasal mucosal ingestion, not collapse of the nasal valve. Therefore, the examiner should be wary of the validity of this test with regard to nasal valve integrity.)
Advanced imaging studies (CT scan) are not necessary to diagnose a deviated septum. However, CT or in-office cone-beam computed tomography (CBCT) are helpful in the evaluation of the location and extent of the deviation and in the assessment of the turbinates, paranasal sinuses, and other related structures for additional pathology. The panoramic radiograph is not used for definitive evaluation of the nasal septum. However, this routinely obtained plain film does afford basic two-dimensional anteroposterior visualization of the septal position and can be used as a screening tool.
In the current patient, axial and coronal CBCT imaging demonstrated significant leftward deviation of the septum with reduced air space and compensatory enlargement of the right inferior turbinate (Figure 13-11, A and B). The panoramic radiograph obtained for third molar evaluation in this patient, shows impaction of the mandibular third molars, and also demonstrates the deviated septum (Figure 13-11, C).
No routine laboratory tests are indicated for nasal septoplasty surgery in an otherwise healthy patient. However, patients with a family history of clotting disorders are screened for possible undiagnosed coagulopathies (e.g., von Willebrand disease, platelet deficits or dysfunction, liver pathology, and clotting factor deficiencies). Patients taking anticoagulant medications are at risk for hematoma formation and uncontrolled hemorrhage.
Severely deviated nasal septum to the left involving the quadrangular cartilage and the bony septum, causing impaired left nostril airflow and compromised flow in the right due to compensatory inferior turbinate hypertrophy. Impacted symptomatic mandibular third molars.
In the current patient, general anesthesia was induced and an oral endotracheal tube was placed for airway maintenance and administration of oxygen and anesthetic agents. Two main incisions are used to approach the septum, the Killian incision and the hemitransfixion incision (Figure 13-12). The Killian incision is the most common and is used to approach the septum without direct access to the caudal segment. It is the best in/>