Rhinoplasty Dr Bashar Bizrah Article on: Bony Wall Mobilization: Osteotomies

OSTEOTOMIES

Aims:

1. Mobilization and repositioning of the lateral nasal bones to achieve the desired satisfactory position.
2. Prevention of open roof deformity.

Types:

1. Medial Osteotomies.
2. Lateral Osteotomies.

Additional Osteotomies: This may be needed in crooked noses:

1. Intermediate osteotomies.
2. Transverse osteotomy.

Techniques: We use the following techniques:

I. Medial Osteotomies

1. The instrument used is Masing’ s single guarded osteotome: Right curved, left curved and straight. (Fig. 17 – 4)
2. Usually performed after hump removal or even without hump removal if needed to narrow the bony pyramid. (Fig. 17 -18)
3. Start with left single guarded Masing’ s osteotome on the left side, push the osteotome between the upper lateral cartilage and nasal septum until it reaches the osteocartilagenous junction, try to be as close to the midline as you can. Start tapping and while the osteotome is moving cephalically guard it with your index finger and direct it towards the medial canthus curving laterally. This leaves a more natural root to the nose and avoids cribriform plate injury. Then repeat the same on the right side. (Figs. 7 – 1,2)

II. Lateral Osteotomies

1. Cottle’ s two mm osteotome is used.
2. The osteotomy is carried out via an external stab incision (Bull’s technique).
3. Push the osteotome into the small stab incision and create a subperiosteal tunnel. The tunnel should be as close to the face as possible starting at the inferior border of the bony pyramid one millimeter above the face and moving up cephalically along the desirable path to meet the cephalic end of the medial osteotomy which has already been performed. (Figs. 7 – 1,2)

Fig. 7 - 1. Outlining the sites for medial and lateral osteotomies.

Fig. 7 - 2.     1 . Medial osteotomy: performed by right or left Masings single guarded osteotome.
2. Lateral osteotomy performed, through a "nick" on the skin by Catties two mm osteotome.

Fig. 7 - 3. (A) The main indication for transverse osteotomy is when deviation starts from the root of the nose. Main indications of intermediate osteotomy are the spindle shaped, banana shaped and wide bulky lateral bony walls.
(B) Outlining:
1 . Transverse osteotomy
2. Medial osteotomy
3. Intermediate osteotomy
4. Lateral osteotomy

4. The two mm osteotome should not penetrate the endosteum (periosteum of the medial wall of nasal bone). The surgeon knows this when the tone of tapping changes or from your experience. Stop at this endosteum otherwise the lateral nasal wall will collapse in and become depressed. (Fig. 7 – 4)
5. It is essential that the lateral walls are completely mobile for accurate repositioning. The lateral nasal bones are put at the end of the procedure into a satisfactory desired position by careful manipulation with the thumb and index fingers. Bilateral incomplete mobilization leads to an open roof deformity and wide bony pyramid. Unilateral incomplete mobilization leads to the appearance
   of a crooked nose. (Fig. 17 -18)

III. Transverse Osteotomy

1. One main indication is a crooked nose with deviation that starts from the root of the nose.
2. Performed with two mm Cottle’ s osteotome.
3. The osteotome is pushed through the small tab incision at the nasion with the osteotomy then performed between the two cephalic ends of the medial osteotomies. (Fig. 7 – 3)
4. This transverse osteotomy should be performed after medial and lateral osteotomies, if complete mobilization of the lateral wall was incomplete.

IV. Intermediate Osteotomy

1. Main indications :
   • Crooked nose
   • Curved convex lateral nasal wall (Spindle shaped)
   • Banana shaped nasal wall
   • Wide nasal wall
2. With the above mentioned indications if we only do medial and lateral osteotomies, we will only be moving the nose towards the midline and preserving the abnormal shape (banana, spindle). Therefore, intermediate osteotomy is essential to break the convex and concave surfaces of the nasal bones (break the banana or spindle shape), in order to achieve full mobilization and accurate repositioning of the nasal bones. (Fig. 7 – 3)
3. Technique: It is performed in a similar manner to the lateral osteotomy but at a level between medial and lateral osteotomies, usually parallel to the lateral osteotomy or slightly curve obliquely inferiorly towards the face according to the desired path. (Fig. 17 – 18)

Fig. 7 - 4. A broad bony dorsum: Using a bone nippier, a gap is created in the midline at the junction of the nasal bones, then lateral osteotomies are considered to close the gap and narrow the dorsum.

Fig. 7 - 5. Correction of broad bony dorsum.

Hints and complications:

1. Medial osteotomy, if performed aggressively and the medial osteotome is pushed too much towards the root of the nose, may result in:
   • Loss of sense of smell due to fracture of the cribriform plate.
   • Dislocation of the perpendicular plate of the ethmoid causing septal collapse and an intraoperative saddling, which will be followed by additional augmentation procedures.
   • Postoperative frontal oedema and ecchymosis.
2. Lateral osteotomy
   • Periorbital oedema and ecchymosis.
   • Incomplete mobilization of the lateral wall causes an open roof deformity or the appearance of a crooked nose.
   • Excessive mobilization causes depression on the lateral nasal wall.
3. To prevent step deformity. Keep lateral osteotomy close to the face.
4. At the end of the osteotomy procedure and after nasal bone approximation, it is important to check the level of the septum and upper cartilage. The upper lower cartilage and septum may need to be lowered, because of the overlapping following osteotomies.
5. If the nasal bony dorsum is wide and there is no hump, and even after medial, lateral and intermediate osteotomies are performed, there may still be difficulty in approximating the nasal bones due to thick bone at the dorsum. Therefore, it is important to create a gap at the midline of the bony dorsum by removing some of the dorsum bone by a bone nippler, in order to approximate the nasal bone and obtain a narrower bony dorsum. The gap is closed by the approximated nasal bone borders. (Fig. 7 – 5)
6. Performing osteotomies needs a lot of concentration and judgement. Assess the situation very carefully, plan the osteotomy lines and decide if there is the need for intermediate or transverse osteotomies. There are no routine or standard rhinoplasty procedures, therefore osteotomies are not routinely indicated in every rhinoplasty we perform.
7. Cast application: Plaster should be applied like a clip above the lateral osteotomies in order to avoid bone displacement. (Fig. 7 – 6)

Fig. 7 - 1 O (A,BJ A case of wide nose due to spindle shape nasal bones, the situation was dealt with by medial, lateral and intermediate osteotomies. Tip projection and elevation is achieved by the manoeuvres of new dome creation, columellar strut, tip graft and lateral crura overlay technique.

References

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