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Grafts in Rhinoplasty

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Grafts in Rhinoplasty Al - Azhar University Center for Virus Studies and Research Grafts in Rhinoplasty Mohamed Rashad Abdel-Hady1, Olfat Abdel-Aziz Sayed2 and Khaled Mohamed Ahmed Abdel-Rahman3 [email protected], [email protected] and [email protected] 1. Prof. of Otolaryngology, Faculty of medicine, Al-Azhar University. 2. Ass.Prof. of Otolaryngology, Faculty of medicine, Al- Azhar University. 3 Specialist of otolaryngology, Helwan University Hospital. Abstract Old rhinoplasty practice has been often relied on resection of the nasal framework in order to achieve aesthetic and/ or functional objectives. Nowadays, careful dissection, conservative resection, planned framework remodeling, & judicious use of properly selected grafts for augmentation comprise the basis for a structural approach to grafting in rhinoplasty. Aim of the work is to present and evaluate outcomes of using grafts in rhinoplasty. Grafts types, techniques were reviewed. Complications, if encountered, were mentioned. Patient satisfaction was evaluated. Methodology is a prospective study utilized the open rhinoplasty technique, upon 35 patients that suffered from various nasal deformities. Their ages ranged between 18 and 45 years. The followed principles consisted of: 1) A precise definition of the type and cause of abnormality. 2) Definition of the goals. 3) Adequate exposure. 4) Preservation or restoration of normal anatomy 5) Incremental and planned correction. 6) Maintenance of nasal airway. Results are 35 patients operated by the open technique, 23 were males while 12 were females. Of them, 32 cases were fully corrected while, 3 cases were partially corrected. Complications were minimal, occurred in 3 cases. The majority of cases (32 cases) were satisfied while 3 cases were unsatisfied. Conclusion is development of sophisticated grafting techniques has played an integral role in achieving durable aesthetic and functional surgical outcomes in rhinoplasty. Keywords Rhinoplasty, Grafts, Augmentation, Techniques. 1 INTRODUCTION In History, the earliest known record of surgery to operated with the closed rhinoplasty technique, the nose was Egyptian. At that time, Egypt had a cases with psychic problem or cases generally unfit highly developed culture in art, literature and for surgery. science, the glory of which was medicine (Masters and Manchester, 1973). The Edwin Smith papyrus 25 patients (71.4%) were operated in AL-ZAHRAA from ancient Egypt outlines the diagnosis and Hospital, while 10 patients (28.6%) in a private treatment of nasal deformities 3000 years ago hospital. 30 patients (85.7%) were Egyptians while (Garrison, 1917). In 1898, Jacques Joseph, a 5 patients (14.3%) were from other Arab countries. German orthopedic surgeon presented his 24 patients (68.57%) were males and 11patients revolutionary concepts of nasal surgery to the (31.42%) were females. Medical Society of Berlin. He is considered by many rhinoplasty surgeons as the father of modern The principles that were followed in the work rhinoplasty (McDowell, 1952). Old rhinoplasty consisted of: 1) A precise definition of the practice has been often relied on resection of the abnormality present and the cause of these nasal framework in order to achieve aesthetic and/ abnormalities, as far as can be ascertained from or functional objectives. The resulted loss of preoperative examination.2) Definition of the goals structural integrity would often lead to poor to be achieved. 3) Adequate exposure of the durability of aesthetic outcomes and progressive deformity. 4) Preservation or restoration of normal functional impairment. This has called the need for anatomy 5) Incremental and planned correction of the development of grafting approaches in modern the specific abnormalities identified. 6) rhinoplasty. Nowadays, careful dissection, Maintenance of the nasal airway. conservative resection, planned framework History taking remodeling & judicious use of properly selected The patients were admitted, a detailed and thorough grafts for comprise the basis for a structural nasal history was obtained. A discussion about approach to grafting in rhinoplasty. Grafts are used patient motivations was carried out. Specific to reconstitute compromised supportive elements questions regarding previous trauma, previous nasal and to rebuild nasal framework in case of structural or sinus surgery, nasal allergy, tobacco, and drug deficiency in order to effect the desired change. use provide important information regarding nasal function. A list of current and past medications for PATIENTS AND METHODS treatment of allergies and nasal or sinus problems This is a prospective study conducted upon 35 were obtained. patients that suffered from various nasal Physical Examination deformities, from April 2013 to January 2016. Their Thorough clinical examination is done to all a cases ages ranged between 18 and 45 years (Mean age 32 including: years). A-External examination: 1-Inspection of the nose Cases included in the study: cases operated by the begins with observation of the patient during quiet open rhinoplasty with grafting technique. The Main respiration. Note whether the patient is breathing deformities included were: saddle nose, crocked through the mouth or nose, document collapse of nose, flaring base, retracted ala and tip ptosis. the lateral nasal sidewalls if present. The sebaceous Cases excluded from the study: cases younger than gland concentration in the nasal skin is also noted, 18 or older than 45, if grafts no applicable, cases as are any scars or other asymmetries. The nasal valve is then observed during sniffing. The external 2 and internal nasal valves are then examined and The Cottle maneuver is performed in all patients evaluated. External valve collapse may be noted in with nasal airflow obstruction. This is performed by thin-skinned individuals with narrow nostrils. pulling the midfacial soft tissue laterally at the Collapse of the internal nasal valve is a much more common cause. The role of the depressor nasi septi muscle is evaluated by examining the tip during melolabial folds. Improvement in nasal airflow is animation on both frontal and profile views. diagnostic for internal nasal valve collapse. 2-Palpation: Bony and cartilaginous irregularities A modified Cottle maneuver may be performed are identified. The thickness of the skin is verified. using a cerumen loop to manually lateralize the Gentle ballottement of nasal tip gives information upper lateral cartilages endonasally. Improvement regarding its structural integrity and support. in nasal airflow during this maneuver is helpful in Ballottement (tip recoil test) of the nasal tip gives predicting the success of nasal valve surgery. information regarding tip support. 3-Decongestant examination: topical Bidigital manipulation of the caudal septum and its phenylephrine was applied using an atomizer. The relationship to the medial crura can be obtained by inferior turbinate was examined and compared with gently grasping and rotating the columella. the nondecongested state. Any new septal B-Internal nasal examination 1-Nondecongested deflections, septal spurs, or deviations of the examination: A speculum examination of the nasal perpendicular plate of the ethmoid was noted. The cavity and assessing the nasal airway is important. internal and external nasal valves were again The internal nasal valve is formed by the caudal examined in the manner outlined above. edge of the upper lateral cartilage, septum, and the Photography and Analysis floor of the nose. This area is the single greatest Photography (frontal, basal, lateral, and oblique contributor to airway resistance and is examined in views) followed by nasofacial analysis were every rhinoplasty candidate. performed systematically in every patient to If a cause of nasal obstruction is not found evaluate for the possible presence of facial anteriorly, a fiberoptic examination of the anomalies and to determine the nasal deformity. The nasopharynx should be performed. following guide was applied for analysis: Assessing for the presence or absence of septal Frontal View:Twisted or straight: Follow brow-tip cartilage is also wise. This is especially important in aesthetic lines. Width: Narrow, wide, normal, cases of revision rhinoplasty in which septal "wide-narrow-wide".Tip: Deviated, bulbous, boxy, cartilage may have been previously harvested. Lack asymmetric, amorphous, other. of enough septal cartilage may prompt the surgeon Basal View:Triangularity: Good versus to harvest cartilage from other sources. trapezoidal. Tip: Deviated, wide, bulbous, bifid, 2-Specific tests: asymmetric. Base: Wide, narrow, or normal. Superior tip rotation test: Nasal tip ptosis is a Inspect for caudal septal deviation. Columella: common cause of airway obstruction, especially in Colurnellar/lobule ratio (normal is 2:1 ratio); status the older patient. Superior rotation of the tip with a of medial crural footplates. finger while the patient inspires is a helpful Lateral View: Nasofrontal angle: Shallow or deep maneuver that aids in the diagnosis of this problem. Nasal starting point: High or low. Dorsun: If positive, maneuvers to superiorly rotate and Straight, concavity, or convexity, bony, bony stabilize the nasal tip should be used. cartilaginous, or cartilaginous (i.e., convexity primarily bony, cartilaginous, or both).Nasal length: Normal, short, long.Tip projection: Normal, 3 decreased, or increased. Alar-columellar Oblique View: Does it add anything, or confirm the relationship: Normal or abnormal.Naso-labial
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