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Rhinoplasty

Introduction

  • Both functional and aesthetic attributes
Physiologic Function

Aesthetic Form

  • Warms, humidifies air
  • Olfaction
  • Resonance of speech
  • Immunity
    • Filters particulates
    • Mucosal barrier
  • Prominent facial feature
  • Contributes to facial harmony
  • Important for self-image
    • Self-esteem
    • Social acceptance

Anatomy

Directionality 

Nasal Lamellae

  • The nose is often thought of consisting of three lamellae (or layers) for the purposes of reconstruction, but really all three are required for the nose to be in functional existence.
    • So therefore, these lamellae are important for aesthetic surgery too
  • The support structure that props the nose up on the face is sandwiched between an inner lining and outer covering (sometimes called the skin envelope) to protect it from the elements
  • All three lamellae must be present regardless of the nasal surgery performed and any that are missing due to any defect should be recreated using the “replace like with like” principle
  • The three nasal lamellae and their main constituents are as follows:
    1. Covering
      • Skin
      • Subcutaneous tissue
      • Muscle
      • Blood supply
      • Nerves
    2. Framework
      1. Nasal bones
      2. Septum
      3. Cartilages
    3. Mucosal lining

Skin

Skin thickness varies from cephalic to caudal

  • Thinner and more mobile over the dorsum
  • Thicker and more adherent to the underlying framework at the nasal tip and ala

Skin Appendages

  • More sebaceous glands in general and most concentrated in the caudal third of the nose
    • Faster re-epithelialization after dermabrasion, chemical peel or laser resurfacing

Subcutaneous Tissue

Layers between skin and osteocartilagenous framework:

  1. Superficial musculoaponeurotic system (SMAS)
    • Continuous with the SMAS of the rest of the face
  2. Fibromuscular layer
  3. Deep fatty layer
    1. Contains the nerves and blood vessels
  4. Perioseteum/perichondrium

Muscles

Levator labii superioris alaeque nasi

  • Origin
    • Frontal process of maxilla
  • Insertion:
    • Skin of the lateral nasal ala and upper lip
  • Action
    • Lateral retraction of nasal ala
      • Dilates external nasal valev
    • Elevation of upper lip
    • Creates snarl facial expression
  • Longest named muscle in humans 

 Nasalis (2 parts)

  • Origin:
    • Transverse part: Frontal process of maxilla
    • Alar part: Maxilla
  • Insertion:
    • Transverse part: Nasal bridge aponeurosis (connected to contralateral nasalis transverse part)
    • Alar part: Alar cartilage
  • Action:
    • Transverse part: Constricts nares
    • Alar part: Dilates nares

Depressor septi

  • Origin: Maxilla
  • Insertion: Medial crural footplate
  • Action:
    • Nasal tip depression
    • Upper lip shortening
  • Can be resected during rhinoplasty or temporarily paralyzed with botulinum toxin to prevent a hyperdynamic or ptotic nasal tip during speech
    • May cause a slight ptosis of the upper lip

During smile and speech:

  • The levator labii superiorus alaeque nasi elevates the alar base
  • The depressor septi pulls the nasal tip caudally
Snarl facial expression created by contraction of the Levator labii superioris alaeque nasi (LLSAN).

Nasal Vaults

The nose can be divided into three nasal vaults:

  1. Upper
    • Two nasal bones
  2. Middle
    • Two upper lateral cartilages
  3. Lower
    • Two lower lateral cartilages
*The ala do not contain cartilage
 
  • When evaluating a patient for rhinoplasty, each vault can be considered separately and there are surgical techniques to address each vault individually

Nasal Bones

  • Paired and fused at the midline
  • Comprises the upper 1/3 of the nose
    • Forms the walls of the upper vault
  • Superiorly, fuses with the frontal bone
    • This point is called the nasion
  • Laterally, fuse with frontal process of maxilla
  • Thickens above the level of the medial canthus

Nasal Cartilages

  • There are two paired sets of nasal cartilages
    • Upper and lower
    • Each with a right and left
    • These four quadrants of nasal cartilages are held together by suspensory ligaments at their centerpoint
    • The septum lies between the right and left halves 
      • Effectively, the cartilages like lateral to the septum
  • Therefore, cartilages are named upper and lower lateral cartilages 
    • A paired set of each
    • Total of four individual cartilages that lie lateral to the septum
  • To hold the cartilages in place, they are interlocked with each other caudally and tucked under the nasal bones cephalically
    • Keystone area
      • The cephalic edge of the upper lateral cartilages sits deep to the caudal edge of the nasal bones
        • They overlap approximately 4-6 mm
      • This area of overlap is referred to as the keystone area
        • In masonry, the keystone is a wedge-shaped stone that is placed at the apex of an arch (or vault) to lock all of the stones into place and allow it to bear weight (or hold up under its own weight) 
      • The nasal bones also overlap the septum in this area 
      • This is usually the widest portion of the nasal dorsum
    • Scroll area
      • Caudally, the upper lateral cartilages roll underneath the lower lateral cartilages, forming a scroll-like relationship

 

  • In both the keystone and scroll areas, the upper lateral cartilages lie deep to the nasal bones and lower lateral cartilages respectively
  • Rhinion = junction of upper and middle thirds of the nose
  • The Internal nasal valve is created by the junction of the upper lateral cartilages and the dorsal septum

Aesthetic Subunits of the nose

Patient Evaluation

History
1. Functional concerns
2. Aesthetic concerns
3. Medical history
4. Surgical history
B. Physical exam
1. External exam
2. Intranasal exam
C. Digital imaging
Facial analysis
1. Heights
2. Widths
B. Nasal analysis
1. Frontal view
2. Lateral view
3. Base view

Treatment

Non-Surgical

Surgical

Goals
1. Aesthetic
2. Functional
B. Approach
1. Open
2. Closed (endonasal)
C. Cartilage sources
D. Incisions
E. Dorsum
F. Septoplasty
G. Osteotomies
H. Nasal tip
I. Airway
J. Nasal base
K. Closing the nose

Post-Operative Management

A. External splint
B. Intranasal splints
C. Sutures

Complications

A. Epistaxis
B. Infection
C. Edema
D. Rhinoplasty
E. Extrusion
F. Technical problems
G. Structural disruption