Key words: face center adjustment, mouth breathing can lead to malocclusion, nasal obstruction leads to mouth breathing, poor nasal esthetics, poor nasal function, septorhinoplasty only after malocclusion correction
The indications for secondary septorhinoplasty (after orthognathic surgery in the maxilla) are not fundamentally different from those for primary septorhinoplasty without prior maxillary displacement for malocclusion correction. They are mainly performed because of poor function and/or esthetics.
However, it is not always clear whether the nasal airway obstruction occurred only postoperatively or already existed preoperatively. Thus, mouth breathing caused by early restriction of nasal breathing can be both a factor in the development of an open bite and promote recurrence of the same. Not infrequently, mouth breathing leads to a low position of the tongue with a lack of stimulus for the transverse growth of the maxilla and thus to the formation of a narrow maxilla with unilateral or bilateral crossbite, which can only be treated adequately by transverse maxillary distraction. The functional balance between the tongue and lips, which also plays a decisive role in the stability of the incisors, is also permanently disturbed if nasal breathing is impaired.
When planning maxillomandibular osteotomies, the nose plays a decisive role in facial esthetics. The goal is to adjust the nose to the center of the face, as well as to the maxillary and mandibular centers.
Facial asymmetries often have several components: Nasal bridge, tip, entrance, upper and lower lip, and chin. A crooked, but in itself straight facial axis can appear very disharmonious if the maxilla and mandible are displaced centrally alone, especially if the bridge, tip, and entrance of the nose are crooked. Not least for forensic reasons, the patient must be made aware of this problem in good time. If secondary septorhinoplasty is not an option as an additional operation, correction of the dental midlines and the chin in the direction of the ideal median sagittal plane may have to be omitted, and the entire facial axis will be crooked. Of course, the surgeon cannot make this decision alone without consulting the patient. The indication that the nose can be corrected simultaneously 1 year after the malocclusion correction as part of the removal of the osteosynthesis material is often essential to the patient’s decision-making.
If septorhinoplasty is performed before malocclusion for functional or esthetic reasons, this can have fatal consequences for the shape and function of the nose after malocclusion. Postoperative changes can assume grotesque proportions, since the nose is very sensitive to changes in the bony maxillary base, especially after extensive resections of the septal cartilage (Figs 23-1a and 23-1b). The frequently present mucosal defects of the nasal floor after maxillary dislocation make it difficult to adequately cover cartilage grafts for reconstruction of a preoperated septum. Thus, function and esthetics of the nose should generally be considered only after maxillary relocation.
Corrections within the framework of maxillary osteotomy are dealt with in Chapter 12. They are mainly limited to resections at the base of the cartilaginous septum, corrections of the bony septal ridge and the anterior nasal spine, submucous conchal resection, and modeling osteotomies of the piriform aperture. Complex reconstructions and especially extracorporeal septal corrections (Fig 23-1) can only be performed during secondary septorhinoplasty.
23.2 Treatment process
Key words: cartilage graft, cooling mask, final inspection only after 1 year, local anesthesia and vasoconstriction, nasal plaster then nasal tamponades for 5 days, secondary septorhinoplasty combined with material removal, septum supports, transnasal and transoral intubation
As a rule, secondary septorhinoplasty is performed during the removal of the osteosynthesis material 1 year postoperatively. The procedure is performed under general anesthesia with transoral intubation. If an additional genioplasty is planned to center the facial midline in this area as well, it must be weighed whether to first perform nasal intubation for material removal and chin correction based on the dental mandibular midline, and then switch to oral intubation to correct the nose based on the dental maxillary midline. A prerequisite for precise performance of septorhinoplasty is the avoidance of more severe intraoperative bleeding and swelling, as these do not allow adequate assessment of the surgical outcome. Therefore, infiltration of a local anesthetic with added epinephrine in the area of the septum and external nose should be performed even before the material removal begins. The additional insertion of tamponades soaked in xylometazoline increases the vasoconstrictor effect.
After the first surgical step and oral reintubation, the nasal hair is cut, and the nasal and facial region is disinfected again.
In septorhinoplasty, osteotomies should be performed as late as possible to reduce intraoperative swelling. After osteotomies have been performed, further swelling can be reduced by applying compresses soaked in ice water.