Orthognathic surgery is a well-recognized method to correct dentofacial deformities. The main goal of orthognathic surgery is to improve soft tissue change. Soft tissue changes to the nose have been well documented. Simultaneous rhinoplasty during orthognathic surgery can be performed to correct existing inherent nasal deformities and also the unfavorable changes that arose from the maxillary surgery. Challenges for concurrent nasal surgery with jaw surgery include preoperative, perioperative, and postoperative which can be overcome with meticulous planning and experience. In complex cases, rhinoplasty can be staged in the last 6 months after the orthognathic surgery.
Key points
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The aim of simultaneous rhinoplasty and orthognathic surgery is to correct both dentofacial deformities and nasal deformities of the patients.
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Nasal deformities include inherent nasal deformities or surgically induced nasal changes.
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Challenges exist in assessing the nose accurately postmaxillary osteotomy due to surgical edema and temporary distortion of the nose from nasal intubation.
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Simultaneous rhinoplasty and orthognathic surgery can be carried out for patients with a high degree of satisfaction as it is a single operation, general anesthesia, and postoperative healing.
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Staged rhinoplasty can be performed for cases in which the surgeon feels that simultaneous rhinoplasty is not suitable.
Introduction
Orthognathic surgery (OGS) is an established and recognized method to correct dentofacial deformities. One of the goals of OGS is to exhibit improved soft tissue change, reflecting the optimal correction of the maxilla and mandible. This positive soft tissue change is the result of improved midface support, paranasal areas, nasolabial angles, and proportion of upper lip to lower lip contours. Ultimately, there is a significant improvement in the patient’s postoperative facial profile, esthetics, and function.
The nose is integral to the face. In OGS, particularly maxillary surgeries, the nose plays a critical role in determining its final nasal esthetics. The Le Fort I osteotomy is the most frequently performed maxillary osteotomy in orthognathic surgeries. Soft tissue changes to the nose which are attributed to the maxillary movements have been well documented. Depending on the pre-existing nasal characteristics, these acquired effects can be favorable or unfavorable.
Unfavorable nasal results can happen despite careful planning and execution in placing the maxillomandibular structures in their correct relationship. Such undesirable nasal effects can eclipse the positive results from the bony correction and can be upsetting to both the patient and surgeon. This is more so when the preoperative nasal characteristics seemed to be favorable before the OGS.
Nasal changes from maxillary movement
Widening of the alar base is a common sequela of Le Fort I osteotomy because it entails circumvestibular subperiosteal dissection, an incision that causes the release and splaying of the facial musculature from the underlying bone. There are several documented methods to reduce this effect, including nasal cinch, , V-Y closure, , or preservation of the anterior nasal spine.
Other surgically induced changes in the nose are mostly vector-dependent. Maxillary impaction can cause superior positioning of the nasal tip; alar widening; retraction of the columella at the subnasal region; as well as a decrease in the nasolabial angle. Maxillary advancement can cause cephalic rotation of the nasal tip; increased supratip depression; and shortening of the nasal tip and alar widening. , The resulting effect is an increased nostril shown with a widened and shortened nose. Maxillary down graft can cause inferior repositioning of the alar base and columella. A maxillary setback can cause droopy nasal tip lobule with decreased support for the nasal tip. ,
Nasal morphology and deformities should be carefully recorded during a clinical examination. It is important to take photographic records, including frontal, profile, oblique views; worm’s view and bird’s eye view. Where indicated, a computed tomographic (CT) scan, cone-beam computer tomography scan, or a nasoendoscopy should be carried out.
Nasal deformities can be classified into (1) inherent nasal deformities that can be improved by OGS, (2) inherent nasal deformities that cannot be improved by OGS, and (3) nasal characteristics and deformities that can be worsened by OGS.
Nasal Deformities that Will be Improved by Orthognathic Surgery
There are nasal deformities that can be improved by maxillary surgery. Maxillary advancement and impaction can improve patients with mild nasal hump; droopy or ptotic nasal tip or a narrow alar base. ,
Although maxillary advancement can cause a corresponding decrease in the nasal tip height, its superior rotation can improve the ptotic nasal tip and improve the profile of the nose. This is because the cephalic rotation of the nasal tip can result in (1) straightening of the nasal bridge in patients with a mild dorsal hump or (2) reducing the prominence of a mild nasal hump. Increased maxillary support at the piriform region from maxillary impaction and advancement can also result in widened alar width and this can be advantageous for patients with narrow alar bases. In patients presenting with maxillary asymmetry and corresponding septal deviation, correction of the maxilla asymmetry restores the anterior nasal spine to the midline. A mildly deviated septum can be corrected by releasing the perichondrium of the septal mucosa before the disjunction of the septal cartilage and vomer. Fixing the nasal septum to the corrected anterior nasal spine can improve the deviation. These corrections can be done via the Le Fort I approach.
Nasal Deformities that Will NOT be Improved by Orthognathic Surgery
Some nasal deformities cannot be improved by OGS. These are nasal deformities that will remain unchanged although the effects of the vector of the maxillary movement do not cause untoward effects on the nose.
These include nasal and severe septal deviations; wide nasal bridges; flat or shallow nasal dorsum; moderate to prominent dorsal hump; bifid or flat amorphous nasal tip; wide alar bases; and upturned noses with increased nostril show. ,
Nasal Characteristics and Deformities that Will be Worsened by Orthognathic Surgery
Maxillary advancement is indicated for patients with moderate to severe maxillary hypoplasia. These patients may not present with nasal deformities but may, as a consequence of increased paranasal bony support from large maxillary movements, end up with a less esthetic nasal result. Large maxillary advancements will result in an increased cephalic rotation of the nose with increased nostril show and accentuation of the supratip break. There is also a corresponding decrease in nasal tip height as the nose splays laterally. The nasal bridge can also look comparatively shallower with large advancements.
Nasal deformities, such as a flat or shallow nasal dorsum; bulbous, amorphous nasal tip; wide alar bases; and upturned noses with increased nostril show can potentially look worse after large maxillary impactions and advancement because of the earlier mentioned reasons.
These include nasal deformities arising in syndromic patients, such as cleft lip and palate patients. These patients usually have unchanged or worsened nasal deformities due to large maxillary advancement.
In patients with moderate or large prominent dorsal hump, the dorsal hump may look more prominent with maxillary setbacks. Similarly, patients with the droopy nasal tip will lose further bony support in maxillary setbacks and down grafts resulting in a more ptotic nasal tip.
The case for simultaneous rhinoplasty and orthognathic surgery
Seah and colleagues retrospectively studied 75 Caucasian patients and found that 61% of the patients had mild to prominent cosmetic nasal abnormalities, whereas 19% of the patients had genial deformities. Despite the greater prevalence of patients with nasal deformities than chin deformities, they found that it was common to correct the chin simultaneously but not the nose. With the nose sitting at the prominent part of the face, the authors felt that it was ideal for the nose to be corrected concurrently to achieve a better facial profile and appearance. They suggested that simultaneous rhinoplasty and OGS should be considered for two groups of patients: (1) those with inherent nasal deformities and (2) those who acquired surgically induced nasal deformities from the OGS. They performed nine cases of simultaneous rhinoplasty and orthognathic over a year and found that there were no functional or esthetic complications.
In 1988, Waite and colleagues published a case series of patients who underwent 22 septorhinoplasties and concurrent orthognathic surgeries. Among these patients, 15 cases were with concurrent bimaxillary osteotomies and 7 with isolated bilateral sagittal split osteotomies. The patients were followed up for at least 12 months. Among these patients, they found that 82% of their patients were pleased with their rhinoplasty results, whereas 94% of their patients were pleased with their jaw surgery. Further, 84% would recommend having both surgeries together, whereas 16% would consider a staged nasal surgery.
Waite and colleagues found that rhinoplasty can compensate for unfavorable nasal changes from maxillary procedures. They suggested that patient selection is important for simultaneous rhinoplasty. They also considered patients to be suitable candidates for concurrent surgeries if (1) they have an average noticeable nasal problem and (2) have a reasonable understanding and expectations of the improvement. Other relative indications include morphologic deformities, such as (3) functional nasal septal deviations or deviations that have no significant functional issues. (4) Minor tip defects, such as an excessive amorphous or bulbous tip, can undergo simultaneous tip-plasty, whereas (5) prominent dorsal hump can be straightened or reduced concurrently.
Raffaini and colleagues have the largest cohort to date involving 250 patients who underwent bimaxillary osteotomies and concurrent rhinoplasty over a 9-year period. Like Seah and colleagues, they were also in favor of simultaneous correction of nasal deformities that remain relatively unchanged after OGS, as well as acquired nasal deformities. The authors acknowledged the challenges that existed in assessing the nose accurately after bimaxillary surgery and showed that these could be surmounted by both meticulous preoperative planning. In their large group of patients, all the patients were found to have good functional and esthetic outcomes. Their study found that 94% of the patients felt that they accepted rhinoplasty only because it was included in the single operation together with OGS strengthening the case for concurrent nasal and dentofacial corrections. This was in line with the findings of Waite and colleagues.
Posnick and colleagues studied patients who underwent bimaxillary osteotomies, septoplasties, and turbinoplasties and found an overall satisfaction rate of 95%.
Costa and colleagues performed simultaneous rhinoplasty, bimaxillary osteotomies, and functional endoscopic sinus surgery on 13 patients. They noted that the advent of rigid fixation had allowed concurrent rhinoplasty and OGS because it allowed the safe transfer of the nasal to oral intubation while limiting surgical relapse alluding to one of Waite and colleagues’ observations. In their study, they found that all the patients had good esthetic and functional results and were free of previous rhinosinusitis.
Sun and Steinbacher retrospectively studied a group of 68 orthognathic patients who underwent staged or simultaneous rhinoplasty. Among this cohort of patients, 12 patients underwent simultaneous rhinoplasty with OGS of which 2 underwent bimaxillary osteotomies and 10 had mandibular surgeries. They reported patient satisfaction in the surgical results in both staged and simultaneous groups with no revisions needed at 1.5 years of follow-up.
Besides nonsyndromic patients, the paper by Kinnebrew and Emison in 1987 included patients with a plethora of syndromes showing that concurrent correction of nasal and skeletal structures can be done for this group of patients Some of these patients had Binder’s syndrome, Sainton syndrome, Saethre–Chotzen syndrome, and cleft lip and palate syndrome. Another case study by Seah reported on the feasibility of correcting both the nasal deformity and jaw deformity on a cleft lip and palate patient who underwent bimaxillary osteotomies, genioplasty, and open septorhinoplasty in a single operation.
The advantages of simultaneous rhinoplasty and OGS include a single planning procedure and general anesthesia and postoperative recovery. Infraorbital nerve temporary hypoesthesia, due to the Le Fort I procedure can also make recovery more comfortable for the patient.
Surgical approaches
The choice of surgical approaches to the nose is often dependent on the type of nasal deformity to be corrected. The common approaches are closed rhinoplasty or open rhinoplasty. , ,
Closed rhinoplasty has been reported for correction of isolated dorsal hump reduction or mild saddle nose augmentation during simultaneous rhinoplasty and OGS. , This involves marginal or infracartilaginous incisions or intercartilaginous incisions. Intercartilaginous can gain direct access to the nasal bridge, whereas marginal or infracartilaginous approaches can gain access to the nasal tip as well as the dorsum. For an infracartilaginous incision, it can be further joined to a hemitransfixion incision to give improved surgical access. Alternatively, a separate hemitransfixion or Killian incision can be placed to give access to the septum if septoplasty is required. The benefit of closed rhinoplasty is the absence of a columellar scar, but the challenges include limited surgical exposure.
The open rhinoplasty method is preferred by some surgeons if tip refinement work is required. Raffaini and colleagues reported in their retrospective study that 95% underwent the open rhinoplasty approach. Open rhinoplasty can be performed using an inverted-V, step incision, or V-incision at the narrowest width of the columella with extensions to marginal incisions. This allows excellent visualization of the nasal tip and the dorsum and is useful for complex refinement of the nasal tip. Its drawback is the presence of a columellar scar although this can be minimized with careful and meticulous closure.
The facial degloving approach is the third approach described by Kinnebew and Emision. This approach was first published by Egyedi in 1974 and involves degloving the nose via circumferential intranasal incisions with sharp dissection on the subcutaneous plane over the alar cartilage rims. Dissection can be carried out in a subperiosteal plane to the nasofrontal region superiorly and maxilla laterally, which allows visualization of the nose, the maxilla, and the infraorbital rims. Despite the improved visibility, authors cautioned against using this approach for mild nasal deformities because of the possibility of nasal stenosis attributed to the 360° incisions in the vestibular region. This can contribute to issues with tip definition as well asymmetric nares.
Septoplasty and turbinoplasty
Septal deviation correction can be done via the Le Fort I approach after the down-fracture of the maxilla. This prevents another endonasal mucosal incision. Seah and colleagues. found that maxillary down-fracture allowed easier access to the septum.
Alternatively, the septal deviation can be addressed during septorhinoplasty either via an endonasal septal mucosal approach using hemitransfixion or Killian incisions or through an open rhinoplasty approach via a split-tip technique. In removing the deviated part of the septum, important considerations should be given to preserving at least 10 mm of the caudal and dorsal strut. The resected deviated septum can be further utilized as cartilaginous grafts. With regards to cases with severe septal deviation requiring subtotal cartilage reconstruction, some surgeons prefer to stage the procedure 6 months after the OGS.
Turbinoplasty is not rhinoplasty per se but is part of nasal surgery and helps with improving the nasal airway in patients with hypertrophic inferior turbinates. Enlarged turbinates can be approached after the down-fracture of the maxilla. The nasal mucosa can be incised to gain access to the inferior turbinates, which can be partially resected. In the author’s experience, hemostasis is better controlled when the mucosa of the tubinates as well as the nasal mucosa are sutured with a running 5/0 or 4/0 vicryl suture on a round needle.
Management of dorsal deformities
Problems of the dorsum are likely because of height discrepancies or deviation of the dorsum.
Deviated Nose
Deviation of the nose can be corrected simultaneously with the correction of dentofacial deformity. The deviation may be because of the cartilaginous vault or the nasal bone. In cases where the deviation is the cartilaginous vault, the septum has invariably deviated and it may suffice to perform septoplasty. The use of spreader or septal extended grafts can further aid in its correction. If the maxilla has deviated, then correction of the maxilla will bring the anterior nasal spline (ANS) to the correct position. The inferior caudal septum can then be anchored to the ANS just before the maxillary mucosal closure.
When the nasal bony vault has also deviated, lateral and medial nasal bone osteotomies can be done with either an endonasal method or percutaneous method, or a combination of both. Care must be given to the maxillary bone plates and the osteotomes should not encroach on the plates ( Figs. 1–8 ).
