Rhinoplasty is a double-edged sword regarding the functional nasal airway; it can enhance and improve the nasal airway if done properly, and can severely compromise the nasal airway if not done properly. The composition of the nasal airway includes the internal and external nasal valves, nasal septum, and inferior turbinates. Each of these areas can be addressed by several techniques, described in the body of the text. Nasal septal perforation is another potential complication that may result from septal surgery, which has nonsurgical and surgical methods to treat, and is also described in the body of the text.
Rhinoplasty is a procedure that has potential to compromise or potentially enhance the nasal airway.
Diagnosis of preoperative nasal airway compromise can help inform treatment to preclude complications involving the nasal airway.
Intimate knowledge of airway manipulation and grafting techniques can elevate the rhinoplasty surgeon and their patient care.
Septal surgery poses a risk of septal perforation if the mucoperichondrium does not remain intact.
Many techniques have been described to repair septal perforation; however, no techniques have shown superiority over another.
Rhinoplasty is typically thought of as a cosmetic procedure; however, treatment can have significantly implications for the function of the nasal airway. Nasal obstruction is a common complaint. An esthetically pleasing outcome that significantly compromises nasal airway function may be considered as an unsuccessful result by some surgeons. A recent survey of plastic surgeons shows that nearly 40% of surgeons report difficulty breathing post-rhinoplasty in more than 20% of patients and that almost 30% of these surgeons do not consider themselves to be adequately trained in assessing and managing the airway during a rhinoplasty. The surgeon performing a rhinoplasty procedure must be cognizant of the nasal airway and the effects that their manipulations and alterations in the structure can have on the nasal airway.
Causes of nasal airway compromise
Classically the most commonly recognized causes of anatomically based nasal airway obstruction (NAO) have been recognized as related to abnormalities in one or more of the following structures :
External nasal valve (ENV)
Internal nasal valve (INV)
There are multiple causes of NAO other than anatomic abnormalities ; however, discussion of these other causes is not included in the scope of this work. The work by Villwock and Kuppersmith is a good reference for these other considerations and offers an algorithm for differentiation between causes of NAO.
The ENV is the most caudal aspect of the external nares, and the structures that compromise the ENV include the lateral crus of the lower lateral cartilage (LLC), the medial crus of the LLC, the nasal septum, and the floor of the nose. ENV collapse is caused by an inherent lack of structural integrity, overresection during rhinoplasty, and destabilization during rhinoplasty.
The INV is the middle third of the nasal vault and is made up of the upper lateral cartilage (ULC), the nasal septum, the nasal floor, and the inferior turbinate ( Fig. 1 ). INV collapse is characterized by a decrease in the angle formed between the septum and the ULC, which is typically 10° to 15°.
The nasal septum is a composite structure made of the quadrangular cartilage, the perpendicular plate of the ethmoid bone, and the vomer bone ( Fig. 2 ). Deviation in the nasal septum away from midline can compromise airflow through the nasal airway. Nasal septal deviation is acquired or congenital in nature.
The inferior turbinate is a component of the latera nasal wall, which can hypertrophy and cause a nasal obstruction. The nature of the turbinate hypertrophy may be bony, submucosal, or a combination of both. Often the inferior turbinate hypertrophies in areas opposite the side of nasal septal deviation.
A combination of the ENV and the INV has been referred to as the nasal inlet. This composite structure has influences on the nasal airflow based on the size of the aperture. Although the following discussion is an oversimplification of the airflow within the nasal airway, it can help to conceptualize the ideal approach to the nasal airway during rhinoplasty. Poiseuille equation <SPAN role=presentation tabIndex=0 id=MathJax-Element-1-Frame class=MathJax style="POSITION: relative" data-mathml='(R=8nLπr4)’>(?=8????4)(R=8nLπr4)
( R = 8 n L π r 4 )
regarding flow dynamics shows that flow and pressure is related to airway resistance, length, and radius (Darcy–Weisbach equation can be further applied). Because of the exponential component of the radius variable, changes in this variable have an amplified effect on resistance to flow.
By the same token, Bernoulli principle relates that flow differential between different areas can create a negative pressure effect. The negative pressure can create a collapse of the ENV and/or the INV, creating a decrease in the radius of the nasal inlet. Structural strength helps resist collapse in response to negative airway pressure.
Historically reductive rhinoplasty is associated with decrease in ENV and long-term dissatisfaction with nasal airflow. This is often related to overresection of the LLC for tip refinement, causing weakening of the cartilage or alar scarring and retraction, thereby narrowing the ENV. Destabilization of the cartilaginous components without proper resuspension or reinforcement has been implicated in postoperative NAO.
A retrospective review of several-hundred patients who have had nasal airway repair surgery showed that long-term postoperative moderate or severe NAO was reported at 82%. It also discussed that nasal valve collapse was present but not treated in patients who had septoplasty/turbinoplasty with no satisfactory improvement in airway obstruction. Nasal valve compromise has been reported to be responsible for 70% of nasal resistance.
NAO can exist in a patient who has had rhinoplasty or someone who has not had rhinoplasty before. Proper diagnosis dictates the proper treatment plan for these patients. A patient-tailored approach to treatment of source of NAO yielded improved results.
Patient history and physical examination are important in determining the cause of NAO. Examination can include several methods including palpation to evaluate the structural integrity of cartilage and the cartilaginous junctions, anterior rhinoscopy using a nasal speculum, nasal endoscopy when indicated, acoustic rhinometry, and the Cottle maneuver to evaluate nasal valve function. These all help to determine diagnosis; however, no consensus exists as to which test is best for evaluating nasal valve function.
Treatment of nasal airway obstruction
Although a focus of this article is discussion of the complications relating to rhinoplasty, it is recognized that secondary repair of a nasal airway following rhinoplasty is similar to the repair of a nasal airway without a history of previous rhinoplasty. Nasal valve compromise, whether it is the ENV or INV, following rhinoplasty is often related to overresection of cartilage, destabilization without proper resuspension of structures, and failure to recognize an inherent lack of structural integrity.
Different options exist for treatment of nasal valve collapse including spreader graft, batten grafts, alar valve suspension, and splay grafts. , Evidence is lacking to demonstrate superiority of one method of INV repair compared with other methods; however, currently spreader grafts are considered the gold standard for nasal valve repair. The following discussion of treatment options is colored with the perspective of the senior author (P.K.S.) and treatment of NAO.
A complicating factor in treating post-rhinoplasty nasal obstruction is the difficulty obtaining graft material. If the patient has had previous rhinoplasty and/or septoplasty, it is likely that the septal cartilage has been manipulated in some way. This has implications in the quantity and quality of the cartilage available for harvest. If the septal cartilage is insufficient for reconstructive grafting, then other sites for cartilage harvest must be considered, including auricular cartilage and rib cartilage. Composite grafts may be useful in alar retraction. Alloplastic grafts and xenografts may also be considered but are generally less preferable than autogenous grafts.
External Nasal Valve
Treatment of ENV collapse often includes reconstructing the LLC to a state of increased strength and/or resuspension to an appropriate level. Alar batten grafts are used to increase the length and strengthen the latera crus of the LLC and are placed as an overlay or underlay. An underlay graft is more esthetically pleasing, but an overlay graft typically imparts more structural integrity. The graft can extend to the lateral nasal wall, where it is secured to the periosteum of the piriform rim or it is placed into a soft tissue pocket laterally.
If the source of the collapse is not related to the strength of the cartilage itself, but rather disarticulation between the ULC and the LLC, the cartilage may be resuspended following dissection of the cartilage from the mucoperiosteum.
Internal Nasal Valve
Dorsal hump reduction during rhinoplasty can compromise the attachment of the ULC to the nasal septum, which can cause an inferior and medial displacement of the ULC. This can cause a decrease in the nasal valve angle, thereby compromising airflow through the nasal airway.
The most common method of INV collapse is placement of spreader grafts. Spreader grafts are used to create dorsal aesthetic units, to support a longer nose length, and to increase the nasal tip projection in secondary and tertiary rhinoplasty cases. The spreader graft is fashioned ideally 3 to 4 mm in height and spans the same length as the ULC. The ULC and nasal septum is then separated, and the graft cartilage is placed immediately lateral to the nasal septal cartilage bilaterally in a submucoperichondrial pocket, and the graft cartilage is secured to the septal cartilage using a slow resorbing or permanent suture in a horizontal mattress fashion (see Fig. 1 ).
Nasal septal deviation is a common issue seen in practice. This is primarily present, post-traumatic and post-rhinoplasty. The septum is a composite structure composed of bony and cartilaginous structures, which are ideally both addressed in a septoplasty. The nasal septum is often used as the site for cartilage harvest for grafting in the rhinoplasty. Cartilaginous septum is displaced off the maxillary crest, and it can also have significant deviation caused by buckling or defects in the structural integrity of the cartilage itself.
The septum is primarily addressed at our institution through a Killian incision, and subperichondrial dissection is carried out through the extent of the cartilaginous septum and continued subperiosteally to expose the bony septum. The quadrangular cartilage is then disarticulated from the bony septum. Becker double-action septum scissors are used to create a controlled cut at the superior aspect of a deviation to prevent aberrant fractures that involve the cribriform plate. The deviated portion of the bony septum is then addressed by removal with a double-action punch or Takahashi forceps. Four-millimeter osteotomes are used to remove bony spurs that may exist on the nasal floor.
The cartilaginous septum is then addressed. In cases of primary rhinoplasty the posterior-inferior septum is harvested and saved for grafting during rhinoplasty. Typically, the septum is harvested in a fashion that preserves an L-strut of the dorsal and caudal septum with a dimension of no less than 20 mm, but typically greater. In isolated septoplasty, cartilage may be harvested and/or morselized to remove the deviations. It is usually replaced into the subperiosteal pocket before incision closure. If there is a dislocation of the cartilaginous septum in the anterior aspect, it is secured to the maxillary crest using a long-term resorbable suture to the periosteum.
Addressing hypertrophy is done by several methods. Total (not preferable) and partial turbinectomy has been described, although the development of atrophic rhinitis, also known as ozena or “empty-nose syndrome,” is a potential complication. Turbinectomy addresses soft tissue and hard tissue concerns, but other methods are used to address the individual components.
Several modalities are used to perform submucous resection of the hypertrophied soft tissue including manual instrumentation, microdebrider, electrocautery, laser, and radiofrequency ablation. Meta-analysis of the literature showed outcomes comparing these different modalities. The greatest percentage of patients showed improvement with microdebrider, and poorest percentage of patients showed improvement with manual instrumentation and cryotherapy.
The bony component when not treated as a turbinectomy is performed with turbinate out-fracture, which is achieved with a broad instrument out-fracturing the bone to a more lateral position against the nasal wall. Bony reduction can also be achieved with submucous resection. ,
Nasal septal perforation
Nasal septal perforation is a condition that can present with pain, bleeding, nasal obstruction, crusting, and whistling sounds from the nose. The prevalence of nasal septal perforation has been reported to be 0.9% in the general population. A study of computed tomography scans in an urban population showed the prevalence to be 2.05%, and of these patients, 3 of 76 were noted to have a history of facial surgery. In a review of a 31-year history of septal perforation repair, 62.4% of patients presented with a history of previous rhinoplasty and/or septoplasty. A recent meta-analysis of nasal surgery complications reports an incidence of septal perforation from 0% to 2.6%.
The vascular supply to the mucoperichondrium is from branches of the internal and external carotid arteries and can cause ischemia to the tissue when vascular compromise occurs, in cases of vasculitis and trauma. With ischemia and/or exposure of the underlying septal quandrangular cartilage, necrosis of the cartilage occurs.
The normal laminar airflow that occurs in a nose is thus disrupted, which can create dryness and irritation that can result in crusting around the perforation. Chronic irritation and manipulation of this crust may increase the size of the perforation. , Other complications from a septal perforation may range from minor irritation and perichondritis to chronic epistaxis and loss of septal support, which can result in loss of nasal tip support and a saddle nose deformity. , Septal perforation may go unnoticed in patients up to 39% of the time.
Evaluation includes a history of past surgeries including rhinoplasty and septoplasty. There are multiple causes of septal perforation, which include postsurgical, traumatic, inflammatory (sarcoidosis, Churg-Strauss syndrome, polyangiitis granulomatosis, lupus), infectious (septal abscess, tuberculosis, syphilis), malignancy, and inhaled substances. , A nasal endoscopy is recommended for evaluation of the anatomy of the nasal cavity and to measure the size of the defect, because this may change treatment planning for repair of defect if indicated. It is imperative to evaluate for other potential causes of septal defect.
Initial steps in nonsurgical management include patient counseling to minimize further iatrogenic trauma from digital or exogenous manipulation of the defect. Hygiene of the area should proceed primarily with saline irrigation of the area. Using a lubricant or ointment may prevent from drying the tissue if applied several times daily. If the tissue shows active inflammation as noted on nasal endoscopy an antibacterial ointment may be advisable.
Nasal septal button may also be used as a nonsurgical method for management of a septal perforation and is easily placed in clinic under local or topical anesthetic. , The device is placed with flanges on either side and may be left for up to a year, although some indications for removal of the device include an inability to provide proper hygiene, persistent pain, and increasing size of the defect.
The current state of the literature does not show any consensus recommendations on surgical management for perforations. However, a systematic review showed that the success of repair in perforations less than 2 cm was 93% and decreased to 78% in perforations greater than 2 cm, but this did not control for the different techniques used.
Most techniques described stress obtaining primary closure, whether it is unilateral or bilateral primary closure (see Fig. 2 ). Multiple different flap techniques, random pattern and axial flaps, have been described. A controversial aspect of the closure technique is the use of an intervening graft material between flaps to make a 3-layer closure. Also described are use of acellular dermis solely to reconstruct the defect, which is only recommended in small perforations. Temporalis fascia, cartilage, and polydioxanone plates have been reported for use in between opposing primary closure using local flaps. A systematic review suggests that interpositional grafts reduce failure rate of perforation repair; however, the controversy remains regarding its usefulness.
In cases where previous septoplasty or rhinoplasty was performed, often the septum is harvested for grafting purposes and is scarce beneath the mucoperichondrium or even absent adjacent to the perforation. This makes dissection of the flaps much more difficult.
Nasal septal perforations are an unfortunate but rare complication of nasal surgery, which has an overall good prognosis with proper patient counseling and cessation of habits that can only exacerbate the condition. Knowledge of the nonsurgical and surgical management can enhance patient care by execution of the proper treatment plan or by referral to a surgeon capable of management.
Clinics care points
Overlooking the functional status of the nose can be a major pitfall when considering cosmetic nasal surgery.
Early treatment of functional nasal deficits can often be more easily treated than secondary reconstruction of deficits following cosmetic surgery.
Mobilization of vascular tissue to obturate a nasal septal perforation is absolutely imperative to achieve successful closure of an NSP.
The authors have nothing to disclose.