Dr. Gustave Aufricht’s wisdom, `Rhinoplasty appears to be an easy operation but it’s hard to produce consistently good results`.
Dr. Unger’s text, ` Always aim for perfection. You will never achieve that, but unless you aim for it, you will never come close`.
Most postrhinoplasty problems are directly related to the technique being used by the rhinoplastic surgeon. However, even with the most predictable technique and outstanding surgical skills, our results are influenced and controlled by thickness of the investing skin, strength and contour of the alar cartilages and the uncontrollable and unpredictable nature of scar contracture during the healing process.
As already stated in the previous chapters, in over 90% of cases the author uses the closed rhinoplasty technique of intercartilagenous and marginal incisions with the tip technique (new dome creation, suture fixation, scoring, columellar strut, tip graft and septocolumellar sutures) including conservative hump reduction, osteotomies for full mobilization of the lateral nasal wall, supratip and dorsum autogenous grafts as indicated. In the author’s series of over 3,000 cases of rhinoplasty he has found that this technique is the chosen technique for the people from the Middle East, Indians, Asians, Africans and many Caucasian with normal or thick skin and for correction of tip deformities such as broad, bulbous or underprojected and asymmetric tip. This recommended tip technique revolutionized his rhinoplasties and significantly improved his results. In theory, there should be no technical problems because the natural anatomy of the tip is preserved, strengthened and supported with preservation of the continuity of the lateral crus and a strong tripod of conjoined lateral and medial crura. The medial crus and the dome are supported by grafts, eight mm of the vertical lateral crus is preserved, the hump is conservatively reduced and osteotomies are performed in order to achieve full mobilization of the nasal bones. As needed, supratip and dorsum autogenous grafts are used. This tip technique reduces postoperative problems to 5-15% and even all the unpleasant results are minor problems that are usually directly related to uncontrolled wound contracture and healing, or to the patient not following our postoperative instructions, or in rare cases, due to infection. Since the author adopted this technique in 1993, he has never had to fully redo a tip plasty or rhinoplasty. All minor problems such as mild notching, pinching, nares asymmetry or mild deviation, which are directly related to the unpredictable wound contracture along the alar rim and alar sidewalls, have been corrected under local anaesthesia on the out-patient in a ten minute procedure. More recently, the author has developed a new technique which is largely based on the Goldman’s tip and the I-beam of medial crura but without lateral crus delivery (p. 137). This is in order to keep an intact alar rim and avoid any problems along the alar rim and alar sidewalls such as notching, dimpling, retraction, collapse or asymmetry. The author has been applying this technique for the last two years. In his opinion this technique is very useful to achieve tip projection, definition and refinement. The author has been impressed by the postoperative results achieved when using this technique. The author believes that this method will revolutionize tip surgery and make it simple and safe. It was presented at the Fall meeting of the American Academy of Facial Plastic Surgery in Denver, 2001. The chairmen of the committee have stated that this is an outstanding technique of high quality and scientific integrity.
Reasons for postoperative problems:
- Poor surgical technique:
- Our routine rhinoplasty incisions and excisions (intercartilagenous and transfixion incision, trimming of cephalic lateral crus and caudal septum), will divide the anatomical factors maintaining the tip support. Thus, without considering supportive means to compensate for the loss of tip support caused by our incisions and excisions, the end results are dropped ill-defined tip, retracted or hanging columella, increased alar flare, pollybeak and acute nasolabial angle.
- Hump overtaking: will lead to bony collapse, cartilagenous collapse and depressions.
- Poorly performed osteotomies: when nasal bones have not been fully mobilized, the end result is a crooked looking nose, wide bony pyramid or open roof deformity.
- Surgeon’s inexperience and poor judgement:
This may cause disaster in practice, when surgeons cannot differentiate between true and false hump, true and false pollybeak and if the surgeon has performed hump over-resection and excessive alar trimming.
- The thickness of the investing skin:
Extremely thick skin is the least likely to achieve desirable refinement and definition. The thick skin may fail to contract favourably on the newly reshaped cartilages and lead to excessive soft tissue scar. Also, very thin skin provides almost no cushion to camouflage even the minute skeletal irregularities or contour imperfections. The ideal skin type falls somewhere in between these two types. There needs to be enough subcutaneous skin to provide adequate cushioning over the nasal skeleton, but still allow critical definition to the nasal tip.
Fig. 13 – 2. Supportive means to compensate for the loss of the tip support. New dome creation, scoring, suture fixation, columellar strut and tip grafts. The new dome creation, columellar and tip graft will achieve adequate tip projection, elevation, definition, symmetry, stretch the alar sidewalls and reduce alar flare. The preservation of the continuity of the caudal alar cartilage margin by the bound lateral to medial crus is obtained in order to avoid notching, retraction and pinching. The preservation of eight mm of vertical lateral crus is presumed to avoid alar collapse, asymmetry, retraction, dimpling and bossae formation.
Postrhinoplasty problems: Classification _ Management
|Fig. 13 – 3. Summary of possible postrhinoplasty problems.
- Pinching and alar asymmetry:
- Asymmetrical scoring of the dome.
- Asymmetrical scored dome mattress suture fixation:
A low positioned suture fixation will cause more concavity of lateral crus leading to pinching and asymmetrical nares.
- Borrowing too much lateral crus.
- Excessive trimming of the lateral crus: (Figs. 13 – 14B, 15B, 20A)
This is more common in the endonasal approach of transcartilagenous excision of the cephalic lateral crus. This is performed blindly leading to severe asymmetry, alar collapse and pinching. The author is not abandoning the transcartilage technique but it should be limited and preserved only for those cases of mild bulbousity with thin skin, strong cartilage and adequate projection.
- Tip grafts which have been deviated due to mal-positioned sutures.
- Long columellar strut:
Columellar strut should not reach the spine, it should be two mm above it.
- Inaccurately positioned lateral crus marginal incision sutures:
The lateral crus marginal incisions sutures should be positioned obliquely in such a way as to pull up the lateral crus toward the rim.
- Lateral crus collapse, due to early dehiscance of suture line, due to loose suture or suture being pulled out by the patient.
- Vestibular adhesions:
These are not uncommon at the junction between intercartilagenous and transfix incisions. They pull in the alar side wall, causing pinching and compromises the airway. Prevention by meticulous closure, preservation of tissue and
|Fig. 13 – 4. Conchal cartilage graft: (A) is used to correct collapse and pinching. The graft is pushed through a marginal incision into a lateral crus pocket. (B) A large graft extending more cephalically may be used for correction of value collapse.
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