Rhinoplasty Dr Bashar Bizrah Article on: PostRhinoplasty Probleins and Revision Surgery Part 3: Postrhinoplasty problems

Postrhinoplasty problems: Classification – Management

Pinching and alar asymmetry:

Causes:

• 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 postoperative instruction in the use of antibiotic ointment on a cotton bud that is pushed into the corner of the vestibular apex a few times a day for two weeks after surgery.

Fig. 13 - 4. Conchal cartilage graft: (A) is used to correct alar 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 valve collapse.

Fig. 13 - 5. Moderate alar retraction, is corrected by a strip of conchal cartilage 1 5mm x 2mm. A small nick is made on the alar margin using blade 1 1 . Then a pocket is made medially within and along the alar rim, the strip of conchal cartilage is inserted. Closure by one suture of 4/0 Dexon.

Fig. 13 - 6. Marked alar retraction is corrected by conchal cartilage graft or conchal cartilage skin graft. The incision is made just internal to the alar margin. Then by dissecting caudally, a bed is created for the receipt of the composite graft. The graft is positioned by interrupted 4/0 Dexon.

Treatment:

1. Assess carefully and identify the cause and treat accordingly.
2. Most cases are due to an excessive excision of lateral crura.
   Treatment is by grafting with septal or conchal cartilages. An incision is made two to three mm behind the nostril rim, or the lateral crus marginal incision is used, a precise pocket being created large enough to admit the graft. The graft should be long enough to extend laterally towards the pyriform aperture, wide enough to stimulate the normal lateral crura shape and extend medially towards the dome area. Closure of incision with 4/0 Dexon. (Fig. 13 – 4)

2. Alar retraction:

Causes:

1. Overexcision of lateral crus. (Figs. 13 -13A,18,21)
2. The Goldman’s tip technique. (Fig. 13 – 7)
3. Excessive excision of vestibular skin.
4. Weak alar columellar junction in elongated columella.
5. Congenital cause. (Fig. 13 – 10)

The author always advise delivering the bilateral alar cartilages and trimming both sides equally under direct vision. The endonasal transcartilagenous lateral crus trimming is a blind technique which may cause severe alar retraction. The Goldman tip plasty is based on dividing the lateral crus and vestibular skin leaving an unsupported rim area which will lead to severe alar retraction. The new dome creation and suture fixation technique preserves the continuity of the lateral crus to the medial crus, leaving eight mm of vertical lateral crus. This will minimize the possibility of alar retraction. If the retraction did happen due to wound contracture, it would be minimal. The modified vertical dome division without lateral crus delivery (The Bizrah Modification) would also greatly lessen the possibility of alar retraction.

Treatment:

Minimal retraction of one to two mm is corrected by a rim graft to fill the notched area through a small rim incision. (Fig. 13 – 5)

Fig. 13 - 8. The Simons formula is useful in avoiding the pollybeak. The surgeon controls the bone and cartilage removal but cannot control the skin thickness and the weak medial crura. Therefore, tip supportive means (new dome creation or modified vertical dome division, suture fixation, columellar strut, tip grafts and septocolumellar sutures) should be considered in order to lengthen and strengthen the medial crura and obtain adequate tip projection and elevation. Together with excision of the extra supratip cartilage this will prevent and correct the pollybeak.

In marked alar retraction due to loss of cartilage, a composite conchal graft is used. The cymba concha shape and curvature fit the normal lateral crus. It is best to use the right cymba concha for left alar retraction or vice versa. The graft should be large enough to cover the anatomic size and shape of lateral crus allowing 15% shrinkage. (Fig. 13 – 6)
A rim incision of two to three mm is carried out intranasally behind the rim, it extends from the dome to the pyriform aperture undermining between external and vestibular skin, freeing the adhesion and scar tissue to create a pocket that can be filled by composite conchal graft. The graft should be wide enough to extend from the dome to the sesamoids complex filling the alar rim. Closure of the incision is by 4/ 0 Dexon.

3. Pollybeak formation:

Definition:

The supratip fullness is called pollybeak or parrot-beak deformity. (Fig. 13 – 8)

Causes:

A. True pollybeak

1. Prominent cartilagenous dorsum:
   • High dorsum septum. (Figs. 13 – 9,14C,19,20)
   • Overlapped upper lateral cartilage overriding the dorsum septum.
2. Excessive supratip scarred tissue.
   

B. False pollybeak

1. Low bony dorsum due to hump over-resection.
   • Dropped tip (tip ptosis) due to:
     Loss of tip support: The compensatory measures to support or reconstitute the tip (new dome creation, suture fixation, scoring, columellar strut, tip grafts, septa columellar sutures) have not been considered, as with the classical endonasal transcartilagenous approach of Joseph. (Fig. 13 – 21)
   • Tip pulled down due to:
     – Excessive alar wedge resection pulling down alar sidewalls under tension.
     – The overactive nasolabalis muscle that pulls the tip down during talking, chewing and laughing.

Preventions:

1. At the end of rhinoplasty, push the forefinger into the nasolabial angle, this shows the expected postoperative tip profile in relation to the cartilagenous dorsum. Any excessiveness in the dorsum septum or superior septal angle should be trimmed.
2. During rhinoplasty remove the excess fatty fibrous tissue beneath the skin in
3. the supra tip area. Care should be taken not to destroy the SMAS, its destruction
4. will lead to fibrosis and scarring.
5. Do not overinject with local anaesthesia. This will cause tip oedema and false tip projection. Regularly squeeze out oedema with a gauze pad and finger pressure.
6. A void loss of tip support:
   Mandatory considerations when dealing with patients who have a poor tip support mechanism.
   • Consider new dome creation or modified vertical dome division, suture fixation, columellar strut and tip grafts. (Fig. 8 – 18 and Fig. 13 – 2)
   • Do not overtrim caudal septum and cephalic lateral crus.
   • Use septocolumellar suture to preserve the desired profile.
     The following formula may be useful in avoiding pollybeak (Simon):

The surgeon controls the bone and cartilage hump removal but cannot control the skin thickness and the weak medial crura. Many of the patients in the author’s region have, unfortunately, thick skin and relatively weak medial crura. Therefore, tip supportive means should be considered. (Fig. 13 – 2)

During the operation check and recheck the profile alignment using gradual
progressive reduction of cartilagenous dorsum by dorsum scissors. Check the
profile by finger pressure on the nasolabial angle. Try to maintain a supratip
break.

6. Avoid bony hump over-resection. Consider grafts for augmentation.
7. Preoperative assessment of the nasolabalis muscle by watching the nose mobility while the patient is talking or laughing. If the muscle is overactive consider division.
8. At the end of the procedure, consider applying steri-strips to close the potential supratip space in order to prevent accumulation of blood, fluids and possibly fibrosis at a later date.

Treatment:

Assess carefully the cause of the pollybeak and differentiate between a true and false one (Figs. 13 – 14C,21). Resection of false pollybeak will cause saddling that requires major augmentation. In the author’s experience with a small pollybeak, only a few patients are particularly concerned about it, because the patients in the Gulf region prefer a straight or slightly high dorsum. But at the same time an obvious pollybeak may be regarded by the patient as a persistent hump that will require correction. As mentioned previously Arabs and Indians have a poor tip support mechanism, so compensatory measures for tip support (new dome creation, suture fixation, scoring, columellar strut and tip graft) should be considered to avoid the postrhinoplasty pollybeak.

1. Excision of extra supratip cartilages:
   In most cases this is the only manoeuvre needed to achieve satisfactory results. The dorsum is undermined in an immediate supracartilagenous plane to avoid further trauma and scarring. Excessive dorsum septum, superior septal angle and upper lateral cartilage are trimmed under direct vision with sharp dorsum scissors. Once the desired profile has been achieved, two large pieces of gel foam are firmly taped by steri-strips over the supratip region to prevent accumulation of blood, fluids and the formation of later fibrosis and supratip fullness. An external cast is applied for seven days.
2. Excision of the scarred tissue:
   It is wise to slightly overcorrect, because the supratip thickens postoperatively. Gel foam and pressure taping are essential.
3. In a false pollybeak due to the dropped tip, the tip projection and elevation is achieved by columellar strut, tip grafts and new dome creation or the Bizrah modification of vertical dome division.
4. In a false pollybeak due to bone over-resection, raise the bony dorsum by precise pocket septal or cartilagenous grafts.
5. Division of the overactive nasolabalis muscle through sublabial incision.
6. A combination of the above corrective manoeuvres may be used in a revision procedure.