Rhinoplasty is not so much an art, but rather an architectural undertaking: a methodical approach to reconfiguring the nasal components to give a proportionate nose that both pleases the eye and satisfies functional requirements. The dorsum and dorsal esthetic lines are some of the most important components of the nose in terms of esthetics and function. The middle vault is the critical portion of the nose that will guide the management of the bony vault and the tip. The role of the spreader flap and its extension into the bony vault is stressed to re-create the barrel vaultlike nasal architecture.
Key points
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Preoperative patient preparation is paramount to ensure optimal outcomes.
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The operative technique for the management of the nasal dorsum requires several key steps:
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Component separation to permit preservation of all structural layers and parts.
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Modification of structural components.
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Reassembly of components to mimic the natural state.
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Spreader flaps and grafts are used as needed to achieve a straight, symmetric, and functional nose.
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Power instrumentation may be used to refine tissue modification and facilitate the procedure.
Introduction
Properly executed rhinoplasty is probably the most valuable of all aesthetic procedures done by plastic surgeons. However, there is also no other esthetic procedure less forgiving than nasal surgery. The results of rhinoplasty must be judged over time. The inadequacies of the procedure may not be evident for months or even years. As edema subsides, the skin envelope shrinks, and tissues atrophy as a result of surgical manipulation and the aging process. Management of the cartilaginous or middle vault is critical to controlling the entire rhinoplasty process. It is addressed first before contouring the bony vault or refining the nasal tip. A poorly managed middle vault is a terrible liability that can leave a legacy of esthetic and functional disability. A successful approach to the middle vault and the nasal dorsum is demonstrated here. As is seen, the natural components of the nose are organized as a barrel vault and not a pyramid as a concept in order to engineer one of nature’s most beautiful structures.
Ideally, one would like to demineralize all of the nasal hardscape, reshape and mold as a sculpture, and then harden the tissues again! This is not yet feasible. One is therefore left with reshaping bone and cartilage with cuts and tools, sutures, and adhesives. Power instrumentation provides one of the most efficient, controllable, and least traumatic modalities for remodeling the hard structures. Sutures allow the surgeon to control the more elastic cartilage. Adhesives are used (by the primary author) to seal tissue planes (fibrin sealants) or to fixate grafts (cyanoacrylates).
Introduction
Properly executed rhinoplasty is probably the most valuable of all aesthetic procedures done by plastic surgeons. However, there is also no other esthetic procedure less forgiving than nasal surgery. The results of rhinoplasty must be judged over time. The inadequacies of the procedure may not be evident for months or even years. As edema subsides, the skin envelope shrinks, and tissues atrophy as a result of surgical manipulation and the aging process. Management of the cartilaginous or middle vault is critical to controlling the entire rhinoplasty process. It is addressed first before contouring the bony vault or refining the nasal tip. A poorly managed middle vault is a terrible liability that can leave a legacy of esthetic and functional disability. A successful approach to the middle vault and the nasal dorsum is demonstrated here. As is seen, the natural components of the nose are organized as a barrel vault and not a pyramid as a concept in order to engineer one of nature’s most beautiful structures.
Ideally, one would like to demineralize all of the nasal hardscape, reshape and mold as a sculpture, and then harden the tissues again! This is not yet feasible. One is therefore left with reshaping bone and cartilage with cuts and tools, sutures, and adhesives. Power instrumentation provides one of the most efficient, controllable, and least traumatic modalities for remodeling the hard structures. Sutures allow the surgeon to control the more elastic cartilage. Adhesives are used (by the primary author) to seal tissue planes (fibrin sealants) or to fixate grafts (cyanoacrylates).
Anatomy
The cartilaginous or the middle vault is architecturally similar to a barrel vault ( Fig. 1 ) confluent with the vertical upright of the septum. It consists of lateral alar cartilages, also known as the upper lateral cartilages, which are contiguous with the quadrangular septal cartilage. Aside from the cartilaginous components to define the middle vault, the nasalis muscle also plays an important role in compressing the cartilage and flaring the nostrils. The middle vault, while usually described as containing valves, is actually in its entirety an elastic and dynamic valve in itself that controls airflow.
Skin
The skin of the middle vault is usually thicker than that of the bony vault. It varies depending on size and structures of skin adnexae (eg, oil glands) and can vary in thickness regardless of ethnicity. The adnexae arise within the fatty layer, a thin carpet layer of fat that atrophies as a result of the aging process, surgical manipulation, or disruption of blood supply. The adherent muscle layer or nasalis muscle is also subject to trauma by injudicious blind elevation.
Cartilage
The middle vault consists of upper lateral cartilages, which are contiguous with the quadrangular septal cartilage. As a trapezoidal shape, the upper lateral cartilages arise from the face of the maxilla laterally by ligamentous attachment and extend medially toward the dorsum, where they become confluent with the dorsal edge of the quadrangular septal cartilage ( Fig. 2 ). From a basal view, one can see that the upper lateral cartilages fuse with the septum and create an angle of approximately 15° according to traditional teachings ( Fig. 3 A ). Actually, the upper lateral cartilage moves directly away from the septum at 80° to 90° for a very short distance before curving around to make that acute angle. In reality, there is more of a barrel vault arrangement to the upper lateral cartilage and septum ( Fig. 3 B).
This junction is anatomically recognized as the valve of Minx—the loss of which is responsible for alar collapse and airflow restriction. Cephalically, these cartilages underlap the nasal bones as a shingle relationship. Preservation of the upper lateral cartilage from beneath the nasal dorsum is an important step for spreader flap extension. Caudally, the upper lateral cartilage provides a lip or scroll from which the greater alar cartilages or lower lateral cartilages of the nasal tip will couple. This scroll of cartilage is architecturally an I-beam. It supports the valvular mechanism, and excision of this structure can also contribute to airflow restriction. The bony or upper vault consists of the nasal bones and is also structurally a barrel vault. The 2 bones arise laterally from suture lines along the buttress of bone along the maxilla. The nasal bones, while thin, gradually thicken along this nasomaxillary process. The base width of the nose is defined not so much by the nasal bones, but by the elevation of these maxillary processes as they arise from the face of the maxilla. It is here that bone cuts may be required. Medially, these 2 bones fuse in a suture line confluent with the vertical plate of ethmoid, a thin bony structure that fuses or often overlaps on one side or the other with quadrangular septal cartilage. Cephalically, the nasal bones form suture lines with the frontal process. Behind this frontal process lies the frontal sinus. Caudally, the nasal bones bifurcate as they join the upper lateral cartilages in a forklike fashion overlapping that cartilage. Central to this bifurcation is the keystone region of the nasal hump, where the cartilaginous septum, vertical plate of the ethmoid, upper lateral cartilages, and the nasal bones fuse in an overlapping relationship like grooved shingles. When bone flaps are cut, it is the firm attachment of the upper lateral cartilages laterally that suspend them to the fixed upright of the dorsal septum and vertical plate of ethmoid.
Mucosa
The nasal mucosa provides blood supply to the bone and cartilage, and it functions to provide moisture that humidifies and warms the incoming air. Uninterrupted and carefully preserved nasal lining will serve to ensure nasal function, the loss of which by devascularization and resultant scarring can cause considerable disability.
Inferior Turbinates
Although these appendages of the nasal airway will be treated more thoroughly along with the septum elsewhere in this issue, it is important to recognize the reflective and cooperative relationship these structures bear to the septum, maxillary and pyriform processes, and the middle vault as a whole. The size of these structures is dynamic in relation to all of the bordering structures that must be addressed accordingly because they are baffles that humidify, warm, and regulate airflow in cooperation with the musculocartilaginous function of the middle vault within which they lie.
Preoperative patient evaluation
A thorough examination of the nose including the nasal airway is imperative. Evaluation of the structures and potential problems must be elicited by history and illuminated inspection. Vasoconstricted examination aided by oxymetazoline will permit a more thorough inspection and provides a test for airway resistance as to whether it is structural or congestive. A computerized tomographic 3-dimensional scan is advisable in cases of deviated noses or posttraumatic deformities. This scan will provide information regarding bone thickness, displacement, and causes of airway obstruction. Although digital photographic documentation has been shown to be a valuable tool in presentation to the patient of potential results, the primary author still prefers a 1:1 (life-size) black-and-white photograph taken in the Frankfort horizontal for surgical planning. These photographs by onlay or drawing on the reverse side with a light box permit an accurate life-size blueprint for nasal addition and subtraction. This blueprint will permit precise rhinoplasty.
Preoperative patient preparation
Two weeks before surgery, a meeting is scheduled with the patient to review the photographs and surgical plan. A comprehensive history and physical examination are done to elicit risk factors and to educate the patient. For the ensuing 2 weeks before surgery, the patient is instructed to refrain from all nonsteroidal anti-inflammatory drugs, supplements, vitamins, and herbal and hormonal therapy, including, most importantly, oral contraceptives. Women of childbearing age are instructed to use barrier protection during intercourse for this 2-week period and for 1 month following surgery after oral contraceptives are reinstated because many medications and the interruption of the hormonal therapy can place female patients at greater risk of conception. Five days preoperatively, the patient is instructed to apply mupirocin ointment 2% twice daily to the nostrils in complicated cases where extensive grafting is anticipated or if there has been a prior history of staphylococcal, or specifically, methicillin-resistant Staphylococcus aureus (MRSA) infection. It is also used for all health care workers that are exposed to MRSA. In other routine rhinoplasties in low-risk populations, the use of povidone-iodine ointment can be used in place of the more costly mupirocin. Cautious facial cleansing twice daily during these 5 days with chlorhexidine in an off-label use with appropriate caution to the eyes and mucous membranes is instituted. The patient is asked to refrain from trimming, waxing, or plucking of any nasal hairs in the perioperative period. The patient is also instructed to not have any food or liquids by mouth after midnight. If the surgery is scheduled for the afternoon, the patient is permitted to have clear liquids until 2 to 4 hours before surgery to avoid dehydration. The patient may benefit from self-administration of an antiemetic before leaving home on day of surgery to prevent postoperative emesis. The primary author prefers 40 mg aprepitant given 3 hours before surgical start time.
In the preoperative area, an intravenous line is begun early to hydrate the patient. Through that same venipuncture, 30 cc of blood is withdrawn, and following strict Harvest System protocol (Harvest Technologies, Lakewood, CO, USA), 10 cc of platelet-poor and 6 cc of platelet-rich plasma are prepared for intraoperative use to reduce ecchymosis and to accelerate wound healing—in the primary author’s cases. Clonidine 0.1 mg in older patients and 0.2 mg orally in adolescents and young adults reduce response to vasoconstrictive agents and circulating catecholamines associated with youth. It also helps to reduce perception of postoperative pain. Dexamethasone 4 mg is administered intravenously as a second drug treatment for antiemetic effect, to reduce postoperative edema, and to improve overall well-being following surgery. Infrequent cases of steroid dysphoria have been observed in the older population.
Faber and colleagues pioneered and demonstrated the effectiveness of desmopressin (DDAVP) for orthognathic surgery and epistaxis. The primary author has been using DDAVP routinely for the past 10 years unless a hypercoagulable state has been identified before surgery by history or laboratory tests. An amount of 0.3 μg/kg (14–24 μg range given as 4 μg/mL) administered 30 minutes before surgery will diminish or eliminate postoperative ecchymosis and provide a remarkably dry field for the operator. In the secondary author’s practice, DDAVP is given at the first sight of a less than ideally dry operative field or for a case in which bleeding is anticipated, such as very thick nasal bones. A low dose (0.1 μg/kg) is given initially. If, after 20 minutes, the field is not satisfactorily dry, a second dose is given. A third dose is given if the field is still not ideally dry after yet another 20 minutes. The total dose should not exceed 0.3 μg/kg. Finally, a broad-spectrum antibiotic, such as cefazolin (1 or 2 g) or clindamycin (600 mg if penicillin-sensitive), is given. Vancomycin (500 mg to 1 g) is used if there is a history of previous staphylococcal infection, if the patient is a known MRSA carrier, or if extensive grafting is to be done. The anesthesiologist examines the patient, and a determination of proper airway management is determined. Thigh-high T.E.D. stockings (Covidien, Minneapolis, MN, USA) are applied in all patients, and the patient is taken to the operating room from the preoperative area fully alert and unsedated.
Operating Room
In the operating room, the unsedated alert patient is included in the briefing of the surgical plan with all members of the team included. All members must be in agreement. The operative consent is read aloud to confirm, and any corrections, emissions, or additions are then done.
The anesthesiologist may use general anesthesia or monitored anesthesia care. The authors prefer TIVA (total intravenous anesthetic) using propofol exclusively to minimize malignant hyperthermia and vasodilation that can be experienced with inhalational agents. A flexible laryngeal mask airway is usually used. For longer cases, high-risk cases for aspiration, or anticipated bleeding, a soft flexible armored silicone Rusch endotracheal tube (Teleflex, Morrisville, NC, USA) is used and secured to the central incisors with dental tape. The eyes are immediately covered with Tegaderm polyurethane patches (3M, Maplewood, MN, USA). Sequential compression devices are applied to the calves, and a pillow is placed under the knees. A Foley catheter (Bard Medical, Covington, GA, USA) is rarely placed unless the procedure is expected to extend more than 4.5 to 5 hours; DDAVP also serves to reduce urinary output. The arms are wrapped with circumferential silicone gel pads and placed on the patient’s lap, comfortably supported by articulating arm supports. A shoulder to toe forced-air heating blanket is applied to maintain euthermia. Temperature is monitored with either axillary or esophageal probes. The table is placed into reflex “chaise” position, and the patient is grounded. The skin is first prepared with 20% isopropyl alcohol to remove any oils, and then markings are done with an indelible single-use gentian violet WriteSite surgical marker (Aspen Surgical, Caledonia, MI, USA). The surgical plan is transferred to the nose by careful measurement taken from the 1:1 photographs placed near the head of the bed for constant reference.
Outlines of the bone and cartilages and proposed addition and subtraction of the substructure are marked, and a W-plasty or an inverted V is designed at the junction of the columella and the upper lip over the anterior nasal spine or where skin thickness changes abruptly from thin to thick. Any alar base reduction incisions are marked as well. The markings in gentian violet are preparation-resistant, and there is no need for tattooing.
The nose is then anesthetized with 4% cocaine-soaked pledgets (1/2 × 2-inch neuro patties). Six pledgets are placed, one in each concha on each side. The tails of the pledgets are tied together so that all 6 will be accounted for during the procedure. No throat packing is done to avoid irritation and increased risk of aspiration, and with open procedures, it should not be required.
Then, 1% lidocaine with epinephrine blocks the infraorbital and infratrochlear nerves and elevates the planes of the nasal dorsum, tip, and columella, usually requiring 12 mL of solution. An additional 3 mL is used on each side internally to elevate the mucoperichondrium off the undersurface of the upper lateral and lower lateral cartilages. The mucoperiosteum is also elevated under the bony hump. If septal or vomer work is done, another 3 mL on each side is expected to be used to lift the mucoperichondrium off the quadrangular septal cartilage and the mucoperiosteum off the vomer. A total of 24 mL may be used in these cases. All injections are done with a 3-mL syringe with a 1-inch 30-gauge needle. Then, 6 mL of the local anesthetic will be reserved on the back table from the 30-mL bottle to be used for turbinates when treated. The secondary author uses a local anesthetic consisting of 2/3 lidocaine HCl (Xylocaine) and 1/3 bupivacaine (Marcaine) with 1:70,000 fresh epinephrine.
The nasal vibrissae are shaved with a disposable handle Bard Parker number 15 blade (ACE Surgical Supply Co., Inc, Brockton, MA, USA), which is a thinner, more flexible blade than the detachable blades. As described by Sheen, the internal nose is prepared with applicators soaked with 10% povidone-iodine. The entire face is then prepared with chlorhexidine cautiously and as an off-label use. Alternatively, 5% povidone-iodine or baby shampoo can be used. The patient is then draped.
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