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Repair of Nasal Deformity Secondary to Congenital Syphilis Through a Coronal Incision

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Repair of Nasal Deformity Secondary to Congenital Syphilis Through a Coronal Incision RepairRepair ofof NasalNasal DeformityDeformity SecondarySecondary toto CongenitalCongenital SyphilisSyphilis ThrouThroughgh aa CoronalCoronal IncisionIncision Angela C. Tsai, BA Jeffrey H. Spiegel, MD, FACS Department of Otolaryngology – Head and Neck Surgery, Boston University School of Medicine, Boston, MA ABSTRACTABSTRACT INTRODUCTIONINTRODUCTION METHODSMETHODS RESULTSRESULTS DISCUSSIONDISCUSSION Objective: Challenges Calvarial bone graft was harvested from the left Patient had significant restoration of his nasal Open Rhinoplasty 1. Describe a novel approach for repair of Underlying defect in the saddle nose is decreased parietal region (see Figure 4). dorsum and greatly improved appearance. (See Although it provides optimal exposure and facilitates saddle nose deformity. septal support resulting in collapse of the nasal dorsum. Graft was then fashioned into a “v” shape that could Figures 2 and 3). precise technique, open rhinoplasty may: 2. Provide an alternative technique for saddle Saddle nose deformity poses various functional and aesthetic rest on the maxillary bone and mimic the native nasal The “tenting” effect provided by the calvarial bones require more extensive dissection and hence nose repair through a coronal incision. 13 challenges, including: bones. resulted in significant improvement in his nasal longer intraoperative time lead to more scar tissue contraction Methods: -nasal obstruction Graft was secured with titanium microplates and airway. -flattened dorsum screws (see Figure 5). The degree of dorsal projection was somewhat cause transcolumellar scarring other complications Literature review and description of a novel -pseudohump Prior to constructing the calvarial bone graft, the soft limited by the amount of soft tissue available, repair of saddle nose deformity in a 39 year old -low tip projection tissue envelope overlying the nasal dorsum was but a highly satisfactory result was achieved. Our Approach male with congenital syphilis and complete Given its minimal invasive technique, benefits may include: agenesis of the nasal bones. elevated. Pathophysiology of Congenital Syphilis The graft was inserted into position through the less handling of soft tissues Results: Occurs in 10.5 per 100,000 live births.1 superior approach. lower risk of post-operative complications such as Due to in utero infection after first 16 weeks of The graft was affixed with additional 4-hole 1.2 mm infection and bleeding A calvarial bone graft was harvested through a gestation when placenta loses its immunological more rapid healing and recovery coronal incision. The bone was fixed with bone screws to the frontal bones (see Figure 6). titanium mini plates into a v-shaped structure barrier. mimicking the natural shape of the nasal Infection with Treponema pallidum causes CONCLUSIONS bones. The graft was inserted into a soft tissue widespread inflammation of nasal mucosa and CONCLUSIONS pocket along the nasal dorsum through the destruction of nasal bones and cartilage.2 Rhinoplasty through the calvarial bone graft harvest same coronal incision and then fixed to the site is a safe and effective alternative to the frontal bone with miniplates. In followup, the Subsequent saddle nose is found in 73% of patients 3 traditional rhinoplasty procedures for select cases patient demonstrated improved dorsal and with congenital syphilis. nasal tip projection, and improved nasal where extensive nasal framework reconstruction patency. He reported a high degree of Reconstruction are necessary. satisfaction with the results. Methods vary based on anatomic abnormality. Benefits include single incision site, sterile working Conclusion: Traditional approach is internal or external rhinoplasty. 5-11 field, decreased intra-operative time, and improved aesthetics and patient satisfaction. Nasal saddle nose deformity, even in the Grafts include rib (autologous or radiated), auricular severe cases resulting from congenital syphilis, cartilage, synthetic materials, and bone. can be successfully accomplished through a single coronal incision resulting in improved Calvarial bone is an excellent choice given its REFERENCESREFERENCES aesthetics and high patient satisfaction. availability, accessibility, and strength. It is also less Figure 1. Lateral view of saddle nose deformity, pre-operative. Figure 2. Corrected saddle nose deformity, intraoperative. 12 Figure 3. Corrected saddle nose deformity, post-op Day 14. 1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2007. prone to infection and resorption. http://www.cdc.gov/std/stats07/syphilis.html. January 2009. 2. McNulty JS, Fassett RL. Syphilis: an otolaryngologic perspective. Laryngoscope. 1981;91(6):889-905. 3. Fiumara NJ, Lessell S. Manifestations of late congenital syphilis: an analysis of 271 patients. Arch Our Patient Dermatol. 1970;102(1):78-83. 4. Daniel RK. Rhinoplasty: septal saddle nose deformity and composite reconstruction. Plast Reconstr Surg. 39 year-old Brazilian male presented with complaint of 2007;119(3):1029-1043. 5. Seltzer, AP. Syphilitic deformity of the nose and its correction; a case report. J Albert Einstein Med Cent nasal deformity (See Figure 1). (Phila). 1957;5(4):251-8. 6. Shipchandler TZ, Chung BJ, Alam DS. Saddle nose deformity reconstruction with a split calvarial bone L- History of recurrent nasal infections shortly after birth, shaped strut. Arch Facial Plast Surg. 2008;10(5):305-11. after which he was diagnosed with and treated for 7. Mutaf M. The anatomic replication technique (ART): a new approach in saddle nose correction. Ann Plast CONTACTCONTACT Surg. 2008;61(2):169-177. congenital syphilis. 8. Okazaki M,Sarukawa S, Fukuda N. A Patient with congenital defect of nasal cartilaginous septal and vomeral bone reconstructed with costal cartilaginous graft. J Craniofac Surg. 2005;16(5);819-822. Reported significant nasal obstruction. 9. Andrade M, Fernandes VS, Boleo-Tome JP. Saddle nose: our approach to the problem. Aesthetic Plast Jeffrey H. Spiegel, MD, FACS Surg. 1999;23(6):403-6. Chief, Division of Facial Plastic and Exam revealed near complete loss of nasal bones, a 10. Taylor SM, Rigby MH. The Taylor saddle effacement: a new technique for correction of saddle nose deformity. Otolaryngol Head Neck Surg. 2008;37(1):105-11. Reconstructive Surgery flat dorsum, lack of septal support, no septal 11. Riechelmann H, Rettinger G. Three-step reconstruction of complex saddle-nose deformities. Arch Boston University School of Medicine perforation. Otolaryngol Head Neck Surg. 2004;130:334-8. 12. Tardy ME, Schwartz M, Parras G. Saddle nose deformity: autogenous graft repair. Facial Plast Surg. Boston, MA 1989;6(2):121-134. 13. Gunter JP. The merits of the open approach in rhinoplasty. Plast Reconstr Surg. Mar 1997;99(3):863-7. www.DrSpiegel.com Figure 4. Calvarial bone graft harvest site. Figure 5. Calvarial bone graft with titanium screws in place. Figure 6. Graft insertion through frontal incision. Email: [email protected].
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