Rhinoplasty Dr Bashar Bizrah Article on: The Crooked Nose Part 2: Principles and Management

Principles of Septorhinoplasty:

1. Improving function.
   Adequate intranasal airways
   Prevention of nasal valve collapse
   CROOKED NOSE
2. Achieving satisfactory cosmetic results by keeping adequate nasal support.

Basic Management :

I. Examination:

1. Examine the dorsum and the nasal sidewalls and list the obvious deformities with good logical judgement :
   Hump – deviation – depression – asymmetry.
2. Examine the nasal cavity with Nasal Endoscopy: assess the nasal septum deviation, enlarged turbinates, polyps formation, allergic rhinitis, mucoid or purulent fluids.

II. Operative Sequence:

1. Endonasal approach: Intercartilagenous, transfixion and marginal incisions
2. Septa! correction
3. Tip surgery
4. Cartilagenous dorsum alignment
5. Bony dorsum alignment
6. Osteotomies
7. Fine – touch bony and cartilagenous dorsum alignment
8. Closure
9. Dressing

Fig. 9 - 3. Septoplasty
     - Leaving adequate caudal margin in order to prevent columellar retraction and dropped tip.
     - Leaving adequate dorsal margin in order to prevent supratip collapse.

Fig. 9 - 4. Division of upper lateral cartilage from the septum. Stay as close to the septum as possible.

III. Surgical Technique:

1. Bilateral intercartilagenous incision.
2. Hemitransfixion incision.
3. Perform septoplasty:
   • Leave adequate caudal margin. (Fig. 9 – 3)
   • Leave adequate dorsal margin.
   • Correct caudal dislocation.
   • Try to preserve cartilage as much as you can.
   • Remove crooked and angled pieces of cartilage and bone.
   • Correct maxillary crest.
4. Dissection of the skin from dorsum. Just deep to the SMAS layer, close to the perichondrium and beneath the periosteum.
5. Division of the upper lateral cartilage from the dorsum septum. (Fig. 9 – 4)
6. Trimming of the curved caudal end of the upper lateral cartilage to achieve normal anatomical shape. (Fig. 17 – 9)
7. Correction of caudal dislocation: (Figs. 8 – 36,39,47,60 and Figs. 9 -1,20,21) In some cases the caudal dislocation pushes the tip component to one side causing deviation of the lower two thirds of the nose. In such cases correction of the caudal septum with consideration of tip support by columellar strut may be adequate to correct the deformity. The deviated caudal septum is conservatively trimmed with 11-blade. Excessive trimming may cause columella retraction and dropped tip. (Fig. 9 – 12, Fig. 16 – 4 and Fig. 17 – 9)
8. Alar delivery: (Fig. 17 -12)
   – Marginal incision.
   -Delivery of the proximal lateral and medial crura and the dome.
   -Removal of fat and scarred tissue from the cartilage.
   -Excision of cephalic strip of lateral crus in order to leave at least eight mm of alar, make sure that both sides left behind are symmetrical and equal.
9. New dome creation:
   Achieving the highest possible domal position, in order to achieve symmetry, elevation and projection. (Fig. 17 – 13)
10. Scoring the new dome:
    Vertical scoring at the highest domal level.
11. Suture fixation of the new dome:
    PDS to suture the highest scored dome. (Fig. 17 -14)

Fig. 9 - 5. Tip plasty: achieving symmetrical tripod of conjoined lateral to medial crura supported by columellar and tip grafts. (New dome creation, scoring, suture fixation, columellar and tip grafts).

Fig. 9 - 6. 
         1. Medial osteotomy
         2. Lateral osteotomy

12. Columellar graft insertion (Fig. 17 -15)
13. Columella support:
    Suturing the bilateral medial crus of alar with the columellar graft in between using 4/ 0 Dexon. (Fig. 9 – 5)
    Aim: Tip elevation – Tip symmetry
    Prevent columellar retraction
14. Tip shield (Sheen) graft: Bevelled, triangular shaped graft is sutured to the new dome of alar cartilage with 4/0 Dexon. (Fig. 17 -16)
    Aim: To achieve tip elevation, definition, projection, symmetry and rotation.
15. Putting the dome cartilages with the tip and columellar grafts back into the normal position.
16. Lateral crura overlay technique:
    Is very useful at this stage in order to obtain a symmetrical tip. If one lateral crura is larger than the other, do not overtrim. The use of the unilateral crura overlay technique on the larger side will achieve tip symmetry. (Fig. 17 -17)
17. Alignment of the dorsum:
    – Cartilagenous and bony.
    – Bony roof should be straight and regular. Upper lateral cartilage and septum should be lowered equally.
18. Hump:
    If hump is present, remove the cartilagenous first, then the bony part.
19. Cartilagenous hump:
    The upper lateral cartilage and nasal septum is lowered with Fomon scissors.
    (Figs. 6 – 4,5 and Figs. 17 – 10,11)
20. Bony hump removed using I-shape osteotome (twelve cm), and the area is made smooth with a rasp, making sure that the bone and cartilage are on the same level.
21. Osteotomies :
    – Medial osteotomy
    – Lateral osteotomy
    – Intermediate osteotomy
    – Transverse osteotomy
    All or some of the above may be required to achieve full mobilization and satisfactory repositioning of the nasal bones. (Figs. 9 – 6,7 and Fig. 9 – 11)

Fig. 9 - 7. All or some of the above osteotomies may be required to achieve full mobilization and accurate repositioning of the nasal
bone.

Fig . 9 - 8. ( l) An on lay graft to prevent supratip collapse. (2) Columellar grarr to support the columella and prevent columella retraction and dropped tip.

Classical medial and lateral osteotomies may not be adequate to achieve straight, well oriented nasal bones. If doing lateral and medial osteotomies alone, the concave and convex margins, the author means, the banana shape will slightly shift from a lateral to a more central position, preserving the banana shape. Therefore, an intermediate osteotomy is essential to break the banana shape and to achieve full mobilization and accurate repositioning of the nasal bones in a straight and symmetrical manner. Again, when deviation starts from the root of the nose (nasion), a transverse osteotomy is mandatory in order to straighten the deviated nasal bones. (Fig. 9 – 11)

22. At this stage if there is no hump and following the correction of the grossly deviated nasal septum, there may be a supratip collapse. Therefore, an augmentation of the supratip area using autogenous grafts, should be carried out at this stage. This is a vital stage of the operation in order to keep support of the cartilagenous supratip. Augmentation of the bony dorsum may be needed as well, to achieve a satisfactory dorsum.
23. An onlay septal graft is reshaped, trimmed, and measured to cover the exact collapsed supra tip area which may need support. The cartilage graft is stitched caudally to the dome of the alar cartilage just behind the tip graft. Double grafts may be needed. (Fig. 9 – 8)
24. Correction of dorsum septum – C-shaped deformity: Following septoplasty and the preservation of the L-shaped septal dorsal and caudal strut, the dorsum septum may still be of a concave and convex shape. The following steps are useful and recommended for correction:
    1. Conservative trimming of the caudal septum may reduce the tension and help to straighten the dorsum septum.
    
    2. The concave side of the C-shape is lightly cross-hatched in a vertical direction to help to reduce the tension of the convexity and to reduce the C-shape of the dorsum septum.
    
    3. Conservative shaving of the prominence of the convex component of the dorsum septum without compromising the integrity of the L-shaped septal strut. (Fig. 9 – 9)
    
    4. Spreader graft on the concave side inserted in a pocket between the dorsum septum and upper lateral cartilage, will act to correct the concavity of the Cshaped deformity. The graft should be made slightly larger than the defect and fixed with 4/ 0 Dexon mattress suture. (Figs. 9 – 9,10 and Figs. 17 – 24 #112)
    
    
    
    
    
    
    
    
    5. If residual concavity exist, an onlay graft is placed on the supratip region above the upper lateral cartilages.
    
    6. For larger C-shaped deformity, bilateral spreader grafts are used to strengthen the C-shaped segment of the dorsum septum. The spreader grafts are applied to concave and convex sides following cross-hatching of the concave side, fixed with 4/ 0 Dexon mattress suture. These bilateral spreader grafts are very helpful in the correction of valve collapse as the spreader graft shifts the upper lateral cartilage laterally. It must be correctly applied in pockets between the dorsum septum and the medial edge of the upper
    lateral cartilage. (Fig. 9 – 10)
25. After such a comprehensive procedure of septoplasty, tip surgery, osteotomies, removal of hump and augmentation, with good judgement through out the procedure, we should now have reached satisfactory results.
26. Septocolumellar sutures:
    Are applied to preserve the already accomplished tip symmetry, projection, definition and rotation. (Fig. 8 – 15)
27. Closure achieved by 4/0 Dexon. Nasal pack inserted, one small Sofratulle each side.
28. Steri-strips applied to the tip and dorsum. (Fig. 17 – 26)
29. Small plaster of paris applied to the bridge and kept in place for one week.