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Perfecting surgery with this 3D structure can take years
to improve the master. Rhinoplasty maneuvers performed today could cause
disastrous results 3 years from now. In rhinoplasty surgery, you learn
from your mistakes.
My fellowship director, J. Regan Thomas, MD, told me
something that I will never forget-“You have not learned anything about
rhinoplasty until you have performed at least a thousand procedures and
followed them for many years.” This statement epitomizes why fellowships
are so valuable. Some of the needed experience and potential pitfalls are
circumvented by first-hand observation, which includes studying the
analysis, judgment, techniques, complication management, and most
importantly, results from a seasoned rhinoplasty surgeon. The training
catapults you years ahead of your colleagues that are not fortunate to
have postgraduate training.
Many of us are taught that aggressive cartilage removal is
a procedure of the past. Today's concept: less is more. Less cartilage
excision, cartilage repositioning, camouflage techniques, structural
grafting, and suturing techniques are being taught in most rhinoplasty
courses and at our national meetings.
In primary rhinoplasty surgery, the keys to preventing
complications are prediagnosis of potential anatomical and functional
abnormalities. For example, a patient desires a dorsal hump reduction and
you identity short nasal bones and a narrow middle vault. Your thorough
evaluation will warn you that this patient is at risk for upper lateral
cartilage subluxation from the nasal bones (inverted V deformity) and
internal valve collapse. In revision nasal surgery, the previous surgeon
missed these telltale potential anatomical abnormalities, and now you are
in charge of repairing the complication. Always perform a detailed
anatomical and functional evaluation of the nose followed by a diagnosis
of the postoperative nasal deformities and/or nasal obstruction. The
incidence of postoperative nasal obstruction is approximately 10%. After
the potential complications are identified, create a surgical plan while
studying the preoperative photographs and prepare to use everything in
your surgical armamentarium since nothing goes as planned.
Consultations
Below is my algorithm for a revision rhinoplasty
consultation, which makes up approximately 25% of my practice. When the
appointment is made, ask patients to bring copies of their medical records
and operative reports from their rhinoplasty surgery or surgeries, in
addition to photographs of their native nose. Initially, review the notes
and photos while the prospective patient discusses surgery with your
patient care coordinator. This will give you a head start on identifying
the problem, assuming that a problem exists. Next, perform a detailed
history while listening carefully to the patient's wishes. Does the
patient have realistic expectations? This is by far the most important
detail that surgeons need to attain from the history. What is the patient
unhappy with-a pinched tip or Polly break deformity? Additionally, listen
to the patient and see if negative comments about the prior surgeon are
made or if potential law suits are mentioned. If this is the scenario, you
may want to think twice about operating on this patient. If the patient is
not happy with the results with you, there is a good chance that the
patient will be saying unkind words about you in the subsequent surgeon's
office. Does the patient fit the SIMON profile (Single, Immature, Male,
Obsessive, and Narcissistic)? If so, be cautious because these patients
are difficult to please and are litiginous. During the initial 5 minutes
while acquiring the patient's history, surgeons should know if the patient
is a good candidate for revision surgery. Poor patient selection can lead
to an unhappy patient and physician.
Another important detail is to ascertain if the patient
has nasal obstruction. Determine if the nasal obstruction was present
preoperatively. If the obstruction is a result of the surgery, a number of
questions need to be answered. Did the patient have reductive rhinoplasty
surgery? Have the patient point out where the obstruction is. Is it static
or dynamic? Does it present with normal or deep inspiration? What
alleviates and worsens the nasal obstruction? What are the characteristics
of the nasal obstruction? Was septal surgery performed?
Examination
For the physical examination, I use a detailed nasal
analysis worksheet (Table 1). Preform a detailed visual and tactile
evaluation of the nose,and use an ungloved finger to palpate the nose.
Examine the bony and cartilaginous skeleton, tip, and skin-soft tissue
envelope characteristics in frontal, lateral, and base views. For the bony
dorsum, examine the osteotomies, presence of open roof deformity or rocker
deformity, and hump under-or over-resection. If inadequate hump reduction
is in question, first examine for a deep radix, under projected, ptotic
nasal tip, and for microgenia. Look for middle vault abnormalities, such as
a narrow middle vault, inverted V deformity, or under-resection of the
caudal cartilaginous dorsum (Polly beak deformity). For the tip, examine
tip projection, rotation, support, alar and columellar retraction,
over-aggressive Weir incisions, and lower lateral crural characteristics,
such as over-resection, cephalically oriented, or bossae formation.
Over-resection of the lower lateral cartilage complex in patients with
a heavy sebaceous skin-soft tissue envelope can cause tip ptosis and nasal
obstruction. A deviated cartilaginous dorsum and tip can signify a
deviated septum. This is only a partial list anatomical problems that
one needs to identify in nasal analysis.
For patients with nasal obstruction, observe the patient
performing normal and deep inspiration on frontal and basal views. Often,
the diagnosis is easily identifiable as supra-alar, alar, and/or rim
collapse or slit-like nostrils during static or dynamic states. External
valve collapse (lower lateral cartilage pathology) can be evaluated with
the soft end of the cotton swab while plugging the contra lateral nostril.
The cotton swab elevates the area of obstruction whether it is the alar
trim, lower lateral crura, or supra-alar region. See if the nasal
obstruction is alleviated by elevating the nasal tip in patients with
ptosis of the nasal thin. Perform the Cottle maneuver (pulling laterally on
the cheek) to check for internal valve collapse. Although this test is
generally nonspecific, internal nasal valve pathology caused by supra-alar
pinching or a narrowed angle between the upper lateral cartilage and
septum can be diagnosed.
On basal view, examine the medial crura to identify if
they are impinging into the nasal airway. Following a thorough external
nasal evaluation, the endonasal examination ensues. At minimum, perform
anterior rhinoscopy with and without topical decongestion. In certain
cases, nasal endoscopy and rhinomanometry may be useful. Evaluate the
nasal septum for perforations, persistent deviation, and for any remaining
cartilaginous remnants to be used for grafting. Other causes of nasal
obstruction to identify are: hypertrophic inferior turbinates, synechiae
between the lateral nasal wall and septum, nasal masses, and middle
turbinate abnormalities (concha bullosa).
As you are examining the patient, create a mental problem
list with solutions followed by documentation on your nasal analysis
sheet, such as: 1)external valve collapse secondary to over-resected lower
lateral crura with a plan of open rhinoplasty with lateral crural strut
grafts using conchal cartilage, 2) internal nasal valve collapse secondary
to a narrowed middle vault and supra-alar pinching with moderate
inspiration with a plan of bilateral spreader grafts and supralar batten
grafts using conchal cartilage, and 3) bilateral alar retraction with a
plan of bilateral conchal composite grafts. If structural grafting is
necessary, decide what material may be used. A thorough knowledge of the
types of autologous septzl, conchal, costal cartilage, and calvarium and
alloplastic grafting is needed as well as harvesting techniques. This is
only an initial plan as you are creating your algorithm. It will change as
you get closer to surgery.
Avoiding Risks
Photo imaging can be extremely useful if patients are
notified that the final image is not a guarantee of results. However,
despite proper notification and consent, there have been reports of
lawsuits filed by patients for outcomes that are different from what was
generated by the photo imager. Photo imaging can give clues to the
patient's expectations. Unrealistic expectations of the patient can be
identified when a surgeon general's a conservative image and the
patient desires a radical change. Therefore, photo imaging can be a
powerful tool in evaluating patients for surgery.
I cannot count the number of times that I have rejected
patients after using the computer to discover their unrealistic
expectations. An additional use for the computer image is to use it as a
foal in surgery. Bring the preoperative and computer imaging photos to the
operating room.
In general, rhinoplasty revision rates are high. Do not
feel pressured to embark on surgery that is beyond your capabilities.
First, do not harm. Know your limitations. Do not hesitate to refer your
patients to colleagues who specialize in rhinoplasty for a second opinion
or to perform the actual surgery. The patient will thank you for being
honest. If you decide to undertake revision nasal surgery, a clear and
thorough knowledge of nasal anatomy and function is paramount. Having an
extensive preoperative discussion, including expectations, outcomes and a
detailed list of potential complications with the patient, can prevent
physician-patient miscommunication. Prior to surgery, review the
examination, previous operative summary, photos, nasal analysis sheet,
problem list and plan and then proceed with the surgical treatment.¯
Paul S. Nassif, MD, FACS, is a facial
plastic and reconstructive surgeon in private practice in Beverly Hills ,
Calif. He is an assistant clinical professor in Facial Plastic and
Reconstructive Surgery at the University of Southern California School of
Medicine and University of California , Los Angeles School of Medicine,
and a member of Plastic Surgery Products' advisory board.
Reference
- Beekhuis GI. Nasal obstruction after rhinoplasty:
enology, and techniques for correction. Laryngoscope 1976;86(4):540-548
Table 1. NASAL ANALYSIS
Patient Name:_________________________Date:_____________________
? Skin Quality: Thin Medium Thick
Sebaceaous
? Primary Description: Big Twisted Large
Hump Boxy Pinched Bulbous
FRONTAL VIEW
? Dorsum: Twisted Deviated Straight
? Convex: R L Bony Bony-Cartilaginous
Cartilaginous
? Width: Narrow Wide Normal
Wide-Narrow-Wide
? Tip: Deviated Bulbous Asymmetric
Amorphous Pinched
? Support : Normal Weak
? Medial Canthal-Alar Relationship: Wide
Normal Narrow
? Tip Defining Points: Uni Double
? Nasal Bones: Short Normal Long
? Middle Vault/Upper Lateral Cartilages:
Narrow Normal Subtuxed Asymmetric
BASE VIEW
? Trapezoidal Triangular
? Tip: Deviated Bulbous Wide Bifid
Asymmetrical
? Base: Wide Narrow Normal Dislocated
Caudal Septum: Y N R L
? Columella: Columellar/lobule Ratio
(2:1)
? Medial Crural Footplates: Wide Normal
LATERAL
? Nasofrontal Angle: Shallow Deep Normal
? Nasal Starting Point: High Low Normal
? Nasal Length: Normal Short Long
? Dorsal Hump: Y N Bony Cartilaginous
? Tip Projection: Normal Decreased
Increased Ratio (0.55-0.60)_____
(TDP AfI/Nasion-TDp)
? Alar-Columellar Relationship : Normal
Abnormal A-C Show_____mm
? Naso-Labial Angle: Obtuse Acute Normal
______Degrees
? Supratip Break : Y N
? Nasal Ptosis: Y N With Smiling: Y N
? Intratip Break: Y N
? Chin: Normal Microgenia Macrogenia
? Columella: Normal Hanging (Septum
Medial Crura Soft Tissue) Retracted
? Ala : Normal Hanging Retracted
? Pollybeak: Y N Cartilaginous Soft Tissue
INTRANASAL
? Septum: Deviated Y N Spur R L
Caudal Deviation Y N R L
__________% Obtsruction R ______________% Obstruction L
Edematous Mucosa Y N Erythematous Mucosa Y N
Perforation Y N If yes, location
__________________________
? Turbinates: Hypertrophic Y N R L Normal
? Internal Nasal Valve: Narrow Normal
? Conchal Cartilage Harvesting: R L
PROBLEM LIST/PLAN:
1._____________________________________________________________
2._____________________________________________________________
3._____________________________________________________________
4._____________________________________________________________
______________________________ _________________
Paul S. Nassif, MD, FACS Date
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