Principles of rhinoplastic reconstruction[edit]

Principles

The technical principles for thesurgicalreconstruction of anosederive from the essential operative principles ofplastic surgery: that the applied procedure and technique(s) yield the most satisfactory functional and aesthetic outcome. Hence, the rhinoplastic reconstruction of a new nasal subunit, of virtually normal appearance, can be done in a few procedural stages, using intranasal tissues to correct defects of themucosa;cartilagebattens to brace againsttissuecontraction and depression (topographic collapse); axialskin flapsdesigned from three-dimensional (3-D) templates derived from the topographic subunits of the nose; and the refinement of the resultant correction with the subcutaneous sculpting ofbone, cartilage, and flesh. Nonetheless, the physician-surgeon and the rhinoplasty patient must abide the fact that the reconstructed nasal subunit is not a nose proper, but acollagen-glued collage of forehead skin, cheek skin, mucosa, vestibular lining, nasal septum, and fragments ofearcartilage which is perceived as a nose only because its contour, skin color, and skin texture are true to the original nose.[33]

Restoration

In nasal reconstruction, the plastic surgeons ultimate goal is recreating the shadows, the contours, the skin color, and the skin texture that define the patients normal nose, as perceived at conversational distance (c. 1.0 metre). Yet, such an aesthetic outcome suggests the application of a more complex surgical approach, which requires that the surgeon balance the patients required rhinoplasty, with the patientsaesthetic ideal(body image). In the context of surgically reconstructing the patients physiognomy, the normal nose is the three-dimensional (3-D) template for replacing the missing part(s) of a nose (aesthetic nasal subunit, aesthetic nasal segment), which the plastic surgeon re-creates using firm, malleable, modelling materials such asbone,cartilage, andflaps of skin and of tissue. In repairing a partial nasal defect (wound), such as that of the alar lobule (the dome above the nostrils), the surgeon uses the undamaged, opposite (contralateral) side of the nose as the 3-D model to fabricate the anatomic template for recreating the deformed nasal subunit, by molding the malleable template material directly upon the normal, undamaged nasal anatomy. To effect a total nasal reconstruction, the template might derive from quotidian observations of the normal nose and from photographs of the patient before he or she suffered the nasal damage.

The surgeon replaces missing parts with tissue of like quality and quantity; nasal lining withmucosa, cartilage with cartilage, bone with bone, and skin with skin that best match the native skin color and skin texture of the damaged nasal subunit. For such surgical repairs, skin flaps are preferable to skin grafts, because skin flaps generally are the superior remedy for matching the color and the texture of nasal skin, better resist tissue contracture, and provide better vascularisation of the nasal skeleton; thus, when there is sufficient skin to allow tissue harvesting, nasal skin is the best source of nasal skin. Furthermore, despite its notablescarringpropensity, the nasal skin flap is the prime consideration for nasal reconstruction, because of its greater verisimilitude.

The most effective nasal reconstruction for repairing a defect (wound) of the nasal skin, is to re-create the entire nasal subunit; thus, the wound is enlarged to comprehend the entire nasal subunit. Technically, this surgical principle permits laying the scars in thetopographictransition zone(s) between and among adjacent aesthetic subunits, which avoids juxtaposing two different types of skin in the same aesthetic subunit, where the differences of color and texture might prove too noticeable, even when reconstructing a nose withskin flaps. Nonetheless, in the final stage of nasal reconstruction replicating the normal nose anatomy by subcutaneous sculpting, the surgeon does have technical allowance to revise the scars, and render them (more) inconspicuous.[34]

Surgical prcis for rhinoplasty[edit]

A rhinoplastic correction can be performed on a patient who is undersedation, undergeneral anaesthesia, or underlocal anaesthesia; initially, alocal anaestheticmixture oflidocaineandepinephrineis injected to numb the area, and temporarily reduce vascularity, thereby limiting any bleeding. Generally, theplastic surgeonfirst separates the nasal skin and thesoft tissuesfrom theosseo-cartilagenousnasal framework, and then corrects (reshapes) them as required, afterwards, sutures the incisions, and then applies either an external or an internal stent, and tape, to immobilize the newly reconstructed nose, and so facilitate the healing of the surgical cuts. Occasionally, the surgeon uses either anautologouscartilage graft or a bone graft, or both, in order to strengthen or to alter the nasal contour(s). The autologous grafts usually are harvested from thenasal septum, but, if it has insufficient cartilage (as can occur in a revision rhinoplasty), then either a costal cartilage graft (from therib cage) or an auricular cartilage graft (conchafrom theear) is harvested from the patients body. When the rhinoplasty requires a bone graft, it is harvested from either thecranium, the hips, or the rib cage; moreover, when neither type of autologous graft is available, a synthetic graft (nasal implant) is used to augment the nasal bridge.[30]

Photographic records[edit]

For the benefit of patient and the physiciansurgeon, a photographic history of the entire rhinoplastic procedure is established; beginning at the pre-operative consultation, continuing during the surgical operation procedures, and concluding with the post-operative outcome. To record the before-and-after physiognomies of the nose and the face of the patient, the specific visual perspectives required are photographs of the nose viewed from the anteroposterior (front-to-back) perspective; the lateral view (profiles), the worms-eye view (from below), the birds-eye view (overhead), and three-quarter-profile views.[9]

Photograph A. Open rhinoplasty:At rhinoplastys end, after the plastic surgeon has sutured (closed) the incisions, the corrected (new) nose will be dressed, taped, and splinted immobile to permit the uninterrupted healing of the surgical incisions. The purple-ink guidelines ensured the surgeons accurate cutting of the defect correction plan.

Photograph B. Open rhinoplasty:The new nose is prepared with paper tape in order to receive the metal nasal-splint that will immobilize it to maintain its correct shape as a new nose.

Photograph A. Open rhinoplasty:Pre-operative, the guidelines (purple) ensured the surgeons accurate incisions in cutting the nasal defect correction plan.

Photograph B. Open rhinoplasty:Post-operative, the taped nose, prepared to receive the metal nasal splint that immobilizes and protects the newly corrected nose.

Photograph C. Open rhinoplasty:The metal nasal splint aids wound healing by protecting the tender tissues of the new nose.

Photograph D. Open rhinoplasty:The taped, splinted, and dressed nose completes the rhinoplasty.

Photograph C. Open rhinoplasty:After the preliminary taping of the nose, a custom-made, metal nasal-splint, designed, cut, and formed by the surgeon, is emplaced to immobilize and protect the tender tissues of the new nose during convalescence.

Photograph D. Open rhinoplasty:The taping, emplacement of the metal splint, and dressing of the new nose complete the rhinoplasty procedure. The patient then convalesces, and the wound dressing will be removed at 1-week post-procedure.

Photograph 2. Open rhinoplasty: The right lower lateral cartilage (blue) is exposed for correction.

Photograph 1. Open rhinoplasty: The columellar incision delineated as a red-dot guideline, will assist the surgeon in the precise suturing of the nose.

Photograph 4. Rhinoplastic correction: A nasal-hump excision plan; the black line delineates the dorsal plane of the new nose.

Photograph 3. Open rhinoplasty: the nasal tip is sutured to narrow the nose.

Photograph 1.Open rhinoplasty:The incisions are endonasal (in the nose), and thus are hidden. The skin-incision to thecolumellaaids the plastic surgeon in precisely suturing to hide thescar except for the columellar incision (red-dot guideline) across thenasalbase. The columellar incision allows the surgeon to view the size, shape, and condition of the nasal cartilages and bones to be corrected.

Photograph 2.Open rhinoplasty:The nasal interior. The scissors indicate thelower lateral cartilage(blue), which is one of the wing-shaped cartilages that conform the tip of the nose. The jagged red delineation indicates the locale of the columellar incision. Once the skin has been lifted from the bone-and-cartilage framework, the surgeon performs the nasal correction tasks.

Photograph 3.Open rhinoplasty:To narrow the tip of a too-wide nose, the surgeon first determines the cause of the excess nasal width. The suture being emplaced will narrow the tip of the nose. The red delineation indicates the edge of the nose-tip cartilage, which is narrowed when the surgeon tightens the folded cartilage apex. The suture (light blue) ends in the needle (white); tweezers (green) hold the nasal cartilage in place for the suturing.

Photograph 4.Nasal hump excision:The black delineation indicates the desired nose-reduction outcome: a straight nose. The nasal hump is bone (red) above the scalloped grey line, and cartilage (blue) below the scalloped grey line. The surgeon cuts the cartilage portion of the hump with ascalpel, and chisels the bone portion with anosteotome(bone chisel). After chiselling away the main mass of the nasal hump with an osteotome, the surgeon then sculpts, refines, and smoothens the cut nasal bones with rasps (files).

Rhinoplastic instruments:Bone-scraping rasps, of various grades and types, that the plastic surgeon uses to refine the corrections required to produce a new nose.

Types of rhinoplasty primary and secondary[edit]

Inplastic surgicalpraxis, the termprimary rhinoplastydenotes an initial (first-time) reconstructive, functional, or aesthetic corrective procedure. The termsecondary rhinoplastydenotes the revision of a failed rhinoplasty, an occurrence in 520 per cent of rhinoplasty operations, hence arevision rhinoplasty. The corrections usual to secondary rhinoplasty include the cosmetic reshaping of the nose because of an unaddressed nasal fracture; a defective tip of the nose, i.e. pinched (too narrow), hooked (parrot beak), or flattened (pug nose); and the restoration of clear airways. Although most revision rhinoplasty procedures are open approach, such a correction is more technically complicated, usually because the nasal support structures either were deformed or destroyed in the primary rhinoplasty; thus the surgeon must re-create the nasal support with cartilage grafts harvested either from theear(auricular cartilage graft) or from therib cage(costal cartilage graft).

Nasal reconstruction[edit]

Rhinoplasty: Right lateral view of thenasal cartilagesand the nasal bone.

Rhinoplasty: Lateral wall of the nasal cavity.

In reconstructive rhinoplasty, the defects and deformities that theplastic surgeonencounters, and must restore to normal function, form, and appearance include broken and displaced nasal bones; disrupted and displaced nasal cartilages; a collapsed bridge of the nose;congenital defect,trauma(blunt,penetrating,blast),autoimmune disorder,cancer, intranasal drug-abuse damages, and failed primary rhinoplasty outcomes. Rhinoplasty reduces bony humps, and re-aligns the nasal bones after they are cut (dissected, resected). Whencartilageis disrupted,suturingfor re-suspension (structural support), or the use of cartilage grafts to camouflage a depression allow the re-establishment of the normal nasal contour of the nose for the patient. When the bridge of the nose is collapsed, rib-cartilage, ear-cartilage, or cranial-bone grafts can be used to restore its anatomic integrity, and thus the aesthetic continuity of the nose. For augmenting the nasal dorsum, autologous cartilage and bone grafts are preferred to (artificial) prostheses, because of the reduced incidence ofhistologicrejection and medical complications.[31]

Surgical anatomy for nasal reconstruction[edit]

Thehuman noseis a sensory organ that is structurally composed of three types of tissue: (i) anosseo-cartilaginoussupport framework (nasal skeleton), (ii) a mucous membrane lining, and (iii) an external skin. The anatomictopographyof the human nose is a graceful blend of convexities, curves, and depressions, the contours of which show the underlying shape of the nasal skeleton. Hence, these anatomic characteristics permit dividing the nose intonasal subunits: (i) the midline (ii) the nose-tip, (iii) the dorsum, (iv) the soft triangles, (v) the alar lobules, and (vi) the lateral walls. Surgically, the borders of the nasal subunits are ideal locations for the scars, whereby is produced a superior aesthetic outcome, a corrected nose with corresponding skin colors and skin textures.[32][33]

Nasal skeleton

Therefore, the successful rhinoplastic outcome depends entirely upon the respective maintenance or restoration of the anatomic integrity of the nasal skeleton, which comprises (a) the nasal bones and the ascending processes of the maxilla in the upper third; (b) the paired upper-lateral cartilages in the middle third; and (c) the lower-lateral, alar cartilages in the lower third. Hence, managing the surgical reconstruction of a damaged, defective, or deformed nose, requires that the plastic surgeon manipulate three (3) anatomic layers:

1. the osseo-cartilagenous framework The upper lateral cartilages that are tightly attached to the (rear) caudal edge of thenasal bonesand thenasal septum; said attachment suspends them above thenasal cavity. The paired alar cartilages configure a tripod-shaped union that supports the lower third of the nose. The paired medial crura conform the central-leg of the tripod, which is attached to the anterior nasal spine and septum, in the midline. The lateral crura compose the second-leg and the third-leg of the tripod, and are attached to the (pear-shaped) pyriform aperture, the nasal-cavity opening at the front of the skull. The dome of the nostrils defines the apex of the alar cartilage, which supports the nasal tip, and is responsible for the light reflex of the tip.

2. the nasal lining A thin layer of vascularmucosathat adheres tightly to the deep surface of the bones and the cartilages of the nose. Said dense adherence to the nasal interior limits the mobility of the mucosa, consequently, only the smallest of mucosal defects (< 5mm) can be sutured primarily.

3. the nasal skin A tight envelope that proceeds inferiorly from the glabella (the smooth prominence between the eyebrows), which then becomes thinner and progressively inelastic (less distensible). The skin of the mid-third of the nose covers the cartilaginous dorsum and the upper lateral cartilages and is relatively elastic, but, at the (far) distal-third of the nose, the skin adheres tightly to the alar cartilages, and is little distensible. The skin and the underlying soft tissues of the alar lobule form a semi-rigid anatomic unit that maintains the graceful curve of the alar rim, and the patency (openness) of the nostrils (anterior nares). To preserve this nasal shape and patency, the replacement of the alar lobule must include a supporting cartilage graft despite the alar lobule not originally containing cartilage; because of its many sebaceous glands, the nasal skin usually is of a smooth (oiled) texture. Moreover, regardingscarrification, when compared to the skin of other facial areas, the skin of the nose generates fine-line scars that usually are inconspicuous, which allows the surgeon to strategically hide the surgical scars.[34]