Rhinoplasty Dr Bashar Bizrah Article on: PostRhinoplasty Probleins and Revision Surgery Part 1

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, supra tip 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:

1. 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.
2. 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.
3. 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.
4. The strength and contour of the alar cartilages:
   The size, shape, position and resilience of the alar cartilages influence the results. The manoeuvres of new dome creation, scoring, suture fixation, lateral crura overlay technique and tip augmentation are required to reshape and strengthen the alar cartilages in order to achieve adequate tip projection, definition and rotation.
5. Wound healing and contracture:
   The natural wound healing contracture and fibrosis can cause uncontrolled problems such as notching, pinching, pollybeak, deviation and asymmetry. These problems could be minimized by the meticulous technique of respecting tissue, preservation of nasal mucosa and vestibular skin and accurately positioned sutures (stitch skin to skin and cartilage to cartilage). The alar rim and the alar sidewalls are thin and very delicate anatomical organs. Therefore, following marginal incision and alar delivery, the uncontrollable fibrosis and scarring are easily shown with unpredictable notching, pinching, dimpling or even collapse.
6. The patient’s misconduct:
   In this region many patients may not adhere to the postoperative instructions, such as early cast removal at home, curious to see the nose, trying to pull down stitches of the marginal incision while cleaning blood clots which may cause lateral ems collapse, sun exposure, early wearing of glasses, practising sports, exposure to trauma particularly by their children or forgetting their postoperative antibiotics leading to infection.
7. Infections:
   In our practice this is very rare because we cover all our patients with antibiotics for ten days. Infection will destroy the cartilage and spoil the operation. This ends with severe contracture and healing problems, then, the revision procedure will need major augmentation and reconstruction.

Non-recommended Techniques:

1. The classic endonasal technique:
   The Joseph and Rees technique without the use of tip and columellar grafts are not recommended. It will almost definitely end with loss of tip support and the unpleasant result of dropped, broad bulbous tip, pollybeak, hanging or retracted columella, alar collapse, acute nasolabial angle and increased alar rim flaring. The Joseph and Rees technique, in the author’s experience should only be preserved for Caucasians of minor bulbousity or minor hump with strong cartilage and adequate tip rotation and projection. (Figs. 13 – 9,13,14,16,18,19,20)
2. The classic Goldman procedure:
   The Goldman classic procedure results in many problems such as pinching, notching, alar retraction and collapse, poor tip definition and asymmetry, unwanted creases, nasal bossae and pointed tip. All these problems are directly related to the division of lateral crura with vestibular skin ( disturbing the continuity of the lateral crura) and are also related to the domal sharp edges which have not been covered by shield tip grafts. (Fig. 13 – 7)
3. Suturing techniques:
   Some surgeons try to achieve the desired tip profile in relation to dorsal profile by only septocolumellar sutures, suturing the trimmed caudal septum to the pulled up medial crura to achieve rotation and projection. In the author’s opinion this is just a misleading manoeuvre and gives false impressions, six to eight weeks later the sutures will be absorbed and the tip which is not being supported by grafts will collapse down again. This suturing technique should only be used to achieve more rotation in patients with an already adequate tip definition, projection, refinement and with strong alar cartilage. The author stresses that the desired dorsum and tip profile should have been achieved without the use of any sutures, because this is how the nose is going to look after a few months. Sutures are only used to preserve and support the desired profile, but not to achieve rotation and projection.

Anatomical factors maintaining tip support:

It is important to understand the anatomical factors that are naturally maintaining the tip support: (Fig. 13 -1)

• Medial crura attachment to the caudal septum.
• Attachment of upper to lower lateral cartilages.
• Ligamentous attachment of superior septal angle to the dome.
• Length and direction of lateral crura.

Major support mechanisms of cartilagenous nose:

1. The dorsum septum.

Fig 1 3 - 1 . Anatomical factor maintaining tip support:
Major I . Attachment of medial crura to the caudal septum
      2. Attachment of upper to lower lateral cartilage
      3. The superior septa! angle
      4. Shape and size of medial crura
Minor 5. lnterdomal attachment
      6. Attachment of dome to overlying skin
      7. Attachment of lateral crura to pyriform aperture
      8. The nasal spine 

Our routine intercartilagenous and transfixion incision with cephalic trimming of the lateral crus will divide all the major anatomical attachments predisposing for loss of tip support and its effects of dropped and bulbous tip, pollybeak, short retracted or hanging columella, acute nasolabial angle and increased alar flare. Therefore, supportive means should be considered to compensate for the loss of tip support. Our key manoeuvres are new dome creation, or modified vertical dome division, suture fixation, columellar strut, tip grafts and septocolumellar sutures. (Figs. 13 – 2 & 3)

2. The caudal septum.
3. The lower lateral cartilages.
4. The upper lateral cartilages.
5. Fibrous attachment between lateral and upper cartilages.
6. Fibrous attachment between caudal margin.

Factors predisposing for loss of tip support and its unpleasant effects:

1. Routine rhinoplasty incisions and excisions:
   The intercartilagenous and transfix incision with cephalic trimming of the lateral crura, will cut or divide all anatomical attachments, predisposing for the loss of tip support (underprojection, dropped bulbous tip, short retracted or hanging columella, pollybeak, acute nasolabial angle and increased alar flare). This reduction rhinoplasty (Joseph rhinoplasty) is still widely practised by many surgeons.
2. Not using columellar strut and tip grafts.
3. Trying to achieve the desired tip profile by only septocolumellar sutures, without the use of columellar and tip grafts.
4. Heavy tip:
   The Caucasian generally has thin skin with strong cartilages, while the Arabs, Indians, Asians and Africans have relatively thick skin, subcutaneous fatty fibrous tissues and softer cartilages. This increases the anatomical weight of the tip compared to the Caucasians. With the postoperative oedema the weight of the tip is doubled or tripled for a few weeks, so after the absorption of the sutures, the tip will drop down due to the effects of gravity, with an increase of septocolumellar redundant soft tissue.
5. Hypertonic nasolabial muscle:
   Strong nasolabial muscle pulls the nose down while laughing, chewing or even during talking. In these cases division of the nasolabalis muscle through sublabial incision will increase rotation and reduce the tension on the tip.
6. Excessive trimming of caudal septum, lateral crus, nasal spine and cartilagenous hump.
7. Transfixion incision has been extended too far down, dividing the attachment between nasal spine and base of the columella.