Rhinoplasty Dr Bashar Bizrah Article on: PostRhinoplasty Probleins and Revision Surgery Part 6: Deviated tip and columella 

11. Deviated tip and columella:

Causes:

1. Collapse of alar side walls due to unequal, excessive trimming of the lateral ems. (Figs. 13 – 16,18)
2. Long columellar strut.
3. Obliquely positioned tip graft.
4. Unequal scoring of the dome leaving one lateral crus longer than the other. The tip will deviate towards the short side.
5. A unilateral flared lateral crura: the flared lateral crura will push the tip towards the opposite side.
6. Unequal correction of bilateral flared lateral crus.
7. Failure to correct caudal septal dislocation.
8. Cleft noses:
   Mild deviation following correction of cleft nose is acceptable.

Treatment:

Carefully assess the cause and treat.

1. Trim long tip grafts and long columellar strut. Columellar strut should be two mm above nasal spine in order to avoid displacement of the graft to one side of the spine.
2. Equal treatment of both sides of the alar by performing a symmetrical dome scoring and suture fixation.
3. Do not overtrim the cephalic lateral crus, thus avoiding blind transcartilagenous trimming.
4. Consider lateral crura overlay technique to reduce supra-alar fullness and flared lateral crus.
5. Consider Batten grafts to support and augment the smaller or overtrimmed lateral crus.
6. Correct caudal dislocation and support the columella with a strut.

Fig. 13 - 15. (Al Patient has spindle shape nasal bones. Medial. lateral and intermediate osteotomles were performed in order to achieve accurate repositioning of the middle nas.1I bones. (BJ Bilateral severe pinching during respiration. This p.itient has very thick skin and has requested tip refinement. The surgeon who performed the operation incorrectly overexcised the bilateral lateral crus. The s1tu,Kion should be corrected by bilater,1I B.1tten gram. In these situations or very thick skin, usually the alar cartilages are very sort. Therefore. It Is wrong to overexcise the lateral crus. The surgeon must leave at least ten to twelve mm of vertical lateral crus and obtain more tip refinement by the manoeuvres or new dome creation or modified vertical dome division. suture fixation. columell.ir strut and double or triple tip grafts and defattening.

12. Wide bony pyramid:

Causes:

1. Incomplete lateral osteotomies. (Figs. 13 -13C,15A)
2. Large intranasal packing as in bleeding and repacking.
3. Uncorrected high septa} deviation that prevents accurate approximation of nasal bones.
4. Excessive polyposis.
5. Enlarged middle turbinates (concha bullosa).
6. Postoperative haematoma and retained bony fragments and debris.
7. Poor correction of initially presented wide convex nasal bones which can be traumatic or congenital.

Treatment:

1. Revise lateral osteotomies to narrow the nasal pyramid. (Figs. 7 – 1,2,3)
2. Consider intermediate osteotomies to break the convexity of the nasal bones.
3. Redo septoplasty, polypectomy or partial trimming of middle turbinates.
4. Use light intranasal packing following rhinoplasty. Use only one small Sofratulle inside. Remove the pack a few hours after surgery, then apply gentle finger pressure on the cast to ensure proper nasal bone approximation and closure of gaps.

13. Open roof deformity:

Due to incomplete lateral osteotomies or resection of large humps. Treatment is by re-osteotornies and application of dorsurn graft as indicated. (Figs. 7 – 1,2)

14. Broad bony dorsum:

Causes:

1. Initially presented but not corrected. Caused by previous trauma or congenital.
2. Bony dorsum fibrosis and calcification. (Fig. 13 -15)

Treatment:

Using a bony 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. (Figs. 7 – 4,5)

15. Deep nasofrontal angle:

Causes:

1. Congenital, seen more commonly in patients with a nasal hump. The criteria is always: deep nasofrontal angle, bony and cartilagenous hump, underdeveloped superior septal angle, short caudal septum, tip underprojection and short colurriella.
2. Inadequate dorsum augmentation not reaching the nasofrontal angle.

Treatment:

During hump removal, the elevation of periosteum of the bony hump will accumulate and fill the nasofrontal angle. The resected bony hump could be pushed up to augment the deep nasofrontal angle or septal cartilage graft can be used for augmentation.

16. Shallow nasofrontal angle:

Fortunately this is rare. It may become more obvious following hump resection. The author’s recommendation is to avoid trauma and overcorrection of this danger zone. Aggressive correction may lead to fibrosis and shallowing.

17. Tip ptosis (dropped or underprojected tip):

The classical endonasal techniques of the blind transcartilagenous excision of cephalic lateral crus without the consideration of compensatory measures to augment or reconstitute the tip (new dome creation, suture fixation, scoring, columellar strut, tip graft and septocolumellar sutures) almost definitely end with dropped, bulbous, asymmetric tip, hanging or retracted columella, acute nasolabial angle and wider nares. (Figs. 13 – 9,13,14,16,18,19,20)

Recommendation:

The use of the tip technique of alar delivery, new dome creation, suture fixation or the Bizrah modification of vertical dome division combined with a columellar strut, shield tip graft and septocolumellar suture.

18. Wide nares:

This is directly resulting from tip ptosis due to increased alar rim flaring. Surgeons using the Joseph and Rees techniques without considering means for tip support, reported alar wedge resection in 80% of their rhinoplasties. The use of new dome creation, columellar strut and tip graft with septocolumellar suture, reduced the need for alar wedge resection to 20%. (Figs. 13 -16,18,20B)

19. Vestibular stenosis:

This rare complication is due to wrongly situated incision that extends too far to the nasal floor and due to aggressive excision of mucousal and vestibular skin. Treatment is difficult and usually by local flaps and composite grafts.

Fig. l 3 - l 7 A. Nasal valve

Fig. l 3 - l 7B. Bossae formation: caused by excessive trimming of cephalic lateral crus leaving too narrow a rim strip that buckles creating the bossae.

20. Problems with Goldman’s tip technique:

The Goldman’s tip technique is based on dividing the vertical lateral ems and vestibular skin, leaving an unsupported area of alar rim and alar sidewall. This causes notching, pinching, alar retraction, bossae formation and pointed tip. (Fig. 13 – 7)

Management:
Notching and pinching are treated by Batten grafts and pointed tip is treated by tip and cap grafts covering the sharp edges of the medial ems.

21. Pointed tip:

As a result of Goldman’s tip technique, it is managed by:

• Delivery of lateral and medial crura.
• Augmentation of the lateral crura with Batten graft extending medially to reach the medial crura.
• A crushed tip Sheen graft.

22. Bossae formation:

Definition:

It is a knoblike protuberance in the dome causing tip asymmetry.

Causes:

1. Leaving too narrow a rim strip that buckles creating the bossae. This is more common in the blind endonasal transcartilagenous lateral ems trimming. (Figs. 13 – 17B,18)
2. Sharp domal edges in the Goldman’s tip.

Treatment:

It is to raise the lower side or to lower the higher side or a combination of both according to which provides the most pleasing results. Then the dome is covered by a crushed shield tip graft.