- Facial Surgery
Incisions are essential in order to approach, reach modify and correct the nasal structure in septorhinoplasty. The septorhinoplasty incisions have a special importance. The intercartilagenous incisions divide the attachment of lateral crus to the upper lateral cartilage and the transfixion incision divides the attachment of the medial crura to the caudal septum. This results in loss of tip support and its unpleasant effects of dropped tip, pollybeak, hanging columella and wider nostrils. Therefore, compensatory means in order to support the tip (new dome creation, or the modified vertical dome division with columellar and tip grafts) are essential manoeuvres following our rhinoplasty incisions. The choices of incisions varies according to the clinical situation. We currently use the following incisions:
– Dorsum undermining.
– Division of upper lateral cartilages from septum.
– Caudal trimming of upper lateral cartilages.
– Conservative trimming of the caudal septum.
Fig. 5-9. Trimming of the curved end of the upper lateral cartilage. (Fig. 17-9)
- – Intercartilagenous incision – 100%
- – Transfixion incision – 95%
- – Marginal incision – 90%
- – Alar wedge incision – 20%
- – Transcolumellar incision – 2%
- Transfixion incisions:
- Modified transfixion incision: Carried out around the superior septal angle and extended down one to two cm inferiorly. It is indicated in cases for hump corrections or mild tip bulbousity where there is adequate tip projection and rotation. (Figs. 5 – 1,2,3)
- Transfixion incisions:
- Hemitransfixion incision: Carried out around the superior septal angle down along caudal septal margin beyond the middle crura-septal attachment. Indicated in cases of hump correction, mild bulbousity and septal deviation where there is adequate tip projection and rotation. (Fig. 17-9)
- Complete transfixion incision: Carried out bilaterally (through and through) around the superior septal angle and down along caudal septal margin beyond the medial crura-septal attachment but stops above the nasal spine. It is indicated in delivery of the alar cartilage, corrections of hump and septal deviation. Compensatory measures (new dome creation, scoring, suture fixation or Bizrah’s modification of vertical dome division with columellar and tip grafts and septocolumellar sutures) should be considered following this type of incision in order to support the tip and achieve adequate tip projection and definition.
- Fig. 5 – 1. Septorhinoplasty incisions
- Intercartilagenous incision: is made at the mucosal-vestibular skin between upper and lower cartilages and carried out medially around the superior septal angle to meet the transfixion incision.
- Transfixion incision: Carried out around the superior septal angle and extend down along the caudal septal margin of two cm.
- Marginal incision: it follows intranasally the caudal margin of the lower latreral cartilage from mid- columella to mid-alar on the vestibular skin.
- Transcolumellar incision: It connects the two marginal incisions at a mid-columellar point in a V or Z design.
- Intercartilagenous incision The intercartilagenous incision is made at the mucosal vestibular skin between upper and lower cartilages from the most lateral point and carried out medially around the superior septal angle and down along the caudal septal margin in hemitransfixion incision. (Figs. 5 – 1,2,3)
- Marginal incision It follows the inferior margin of the lower lateral cartilage from about mid-columella to mid-alar on each side (Figs. 5-1,2,3,). It may as indicated extend from the medial crural foot plate to the pyriform aperture. The skin incision at the columella is made one mm behind the caudal edge at the intermediate and lateral crura to prevent postoperative scarring and alar margin notching and retraction. (Fig. 17-12)
- Transcolumellar incision (external incision) It connects the two marginal incisions at a mid-columellar point in a V or Z design. It may be indicated in: Revision rhinoplasty Severely crooked noses Cleft noses Surgeons with outstanding skills rarely need to employ the external incision. It is employed in only 2% of our cases. (Fig 5-1D and Fig. 17-27)
- Transcartilagenous incision: Reserved for cases of mild bulbousity with strong alar cartilages and adequate tip projection and rotation. The incision is made horizontally into the vestibular skin and lateral crus, the cephalic portion of the lateral crus is then excised with its connected fibro fatty tissue, but with preservation of vestibular skin. The author does not recommend the use of this blind excision of the cephalic lateral crus and feels that it should be applied only in cases of mild bulbousity with strong cartilages, adequate tip projection and rotation. Even so, in these situations, the author strongly recommends the use of columellar strut through a small mid-columellar incision in order to support the tip, following the division of the soft tissue connection between the lateral crus and upper lateral cartilage. Although this technique is not suitable for use with patients in the Middle East, it remains popular in Northern European countries and Canada. Unfortunately, many surgeons in the Middle East do not differentiate between the characteristics of the tip cartilage and soft tissue between such races. Many of the people from the Middle East have what is called the heavy tip (thick skin, subcutaneous fat and soft cartilage), which is predisposed for postrhinoplasty loss of tip support and its unpleasant effects such as dropped tip, pollybeak and wider nares.
- Alar wedge incision: Indications and techniques are discussed fully in the chapter on Alar Wedge excision.
- Keep the incision sharp and delicate and avoid irregularities and cutting across the edges.
- Avoid mucosa and vestibular skin excisions to prevent vestibular stenosis.
- Do not extend the intercartilagenous incision too much laterally in order to avoid dividing the attachment in the cartilage to the pyriform aperture which may cause valve collapse and pinching.
- Do not extend the transfixion incision too much downwards to the nasal spine to avoid excessive loss of tip support.
- Keep your marginal incision close to the caudal margin of the intermediate and lateral crus to avoid notching and scarring of the alar rim.
- Close your marginal incision meticulously using 4/0 Dexon. Stitch skin to skin, never cartilage to skin. (Fig. 5-4)
- Position your marginal incision sutures obliquely in a way high on the alar rim and low on the lateral crus skin in order to pull up the lateral crus to the alar rim to prevent notching, pinching, retraction and nares asymmetry.
- Close your transfixion incision by buried 4/0 Dexon sutures. Trim redundant soft tissue to avoid hanging columella and to avoid later pocket formation and collection of crusts and its unwanted smell. (Fig. 5-4)
- Support the buried Dexon suture of the transfixion incision by two septocolumellar sutures to preserve and support the tip projection.
- Avoid tight strips around the tip which may push the rim in, predisposing for notching
- Always remember that incisions divide the intercartilagenous ligaments and tissue connection, predisposing for the loss of tip support. Therefore, compensatory measures (new dome creation, suture fixation, scoring, columellar strut, tip graft, septocolumellar suture) are mandatory to achieve tip projection, rotation, elevation, definition, refinement and symmetry.
- Dorsum undermining:
Following the intercartilagenous incision:
- Use a sharp scissors to identify the right plane of the caudal upper lateral cartilages.
- Next, use blunt scissors to proceed with skin elevation. Stay close to the cartilage and then adjacent to the nasal bones up to the glabella. (Fig. 5-5)
- Now, Aufricht’s retractor is used to visualize the dorsum.
- Do not undermine too much laterally, elevate only the dorsum in a way that you identify the hump borders, depressions of the deformity to be corrected. Too much lateral dissection may cause bone collapse following lateral or intermediate osteotomy.
- Avoid injury to the SMAS layer and subcutaneous tissue. So stay close to the cartilage and bone. Injury to the SMAS causes intraoperative bleeding, postoperative oedema, later fibrosis, scarring and possible pollybeak formation.
- Do not go beyond the glabella as it will lead to postoperative forehead oedema.
- Division of the upper lateral cartilages
- Subperichondrial bilateral tunnels are made at the junction of the septum to the upper lateral cartilages. (Fig. 5-6)
- A blade No. 11 is pushed through the tunnel and in an upward motion, the septum is divided from the upper lateral cartilage. The Aufricht’s retractor provides exposure and helps to protect the nasal akin.
- It is of most importance that the upper lateral cartilages are divided as closely as possible to the nasal septum in order to avoid the formation of the T-shaped structure. When the T-shaped structure is wrongly formed, it may later cause pollybeak. But if the T-shaped structure is trimmed to lower the dorsum septum, it may lead to supratip collapse. That is because the medial border of the upper lateral cartilages are involved with the trimmed T-shaped structure and will not adequately overlap the dorsum septum, leading to depression of the supratip region.
- Trimming the upper lateral cartilages
- This manoeuvre is necessary in a long nose, drooped tip and crooked nose with upper lateral cartilage asymmetry. However, it is not required in all rhinoplasties.
- At the end of the procedure, if the caudal ends are projecting too far caudally, a small triangle of not more than 1.5mm is excised, with preservation of the mucosa and vestibular skin. (Fig. 5-7)
- Aggressive excision leads to valve collapse and obstructed breathing due to scarring and pinching in this area. (Fig. 5-9)
- Fatty fibrous tissue on the upper lateral cartilages may be excised with the small cartilagenous caudal triangle when the central third of the nose is wide in order to enhance the narrowing effects. (Fig. 17-9)
- Trimming of the caudal septum
- Long nose
- Drooping tip
- Caudal dislocation
- To achieve tip rotation
- To obtain an aesthetic nasolabial angle of 90 degree or slightly greater.
- Trimming of the caudal septum is performed following the intercartilagenous and transfixion incisions, skin elevation and division of upper lateral cartilage from the septum. In the author’s experience, that part of the caudal septum which is projecting caudally beyond the caudal margin of the transfixion incision, on the resting position, should be trimmed. (Fig. 5-8, Fig. 9-12 and Fig 17-10)
- The caudal septum is divided into thirds. If only rotation is required, the outer third is excised. In drooped tip and columellar the outer two thirds are
- trimmed. In more advanced cases of long nose, overprojected tip and overdeveloped caudal septum the entire caudal septum is trimmed and may be, as required, the nasal spine is partially reduced. (Fig. 17-19)
- Following trimming of the caudal septum. It is of most importance to consider supportive means to compensate for the loss of the tip support caused by our incision and excisions which divide the natural anatomical ligaments and attachments of the tip to the caudal septum, superior septal angle and upper lateral cartilages. Disregarding these supportive means will end with dropped tip, retracted or hanging columella, pollybeak and wide nares.