Rhinoplasty ARTICLE BY PHILIP WILKES, CST/CFA hinoplasty is plastic become lodged in children's noses.3 glabella, laterally with the maxilla, surgery of the nose Fortunately, the art and science of inferiorly with the upper lateral car- for reconstructive, rhinoplasty in the hands of a skilled tilages, and posteriorly with the eth- restorative, or cos- surgical team offers positive alter- moid bone? metic purposes. The natives. The nasal septum is formed by procedure of rhmo- Three general types of rhino- the ethmoid (perpendicular plate) plasty had its beginnings in India plasty will be discussed in this arti- and vomer bones (see Figure 5). The around 800 B.c.,as an ancient art cle. They include partial, complete, cartilaginous part is formed by sep- performed by Koomas Potters.' and finesse rhinoplasties. tal and vomeronasal cartilages. The Crimes were often punished by the anterior portion consists of the amputation of the offender's nose, Anatomy and Physiology of the medial crus of the greater alar carti- creating a market for prosthetic sub- Nose lages, called the columella nasi? stitutes. The skill of the Koomas The nose is the olfactory organ that The vestibule is the cave-like area enabled them to supply this need. In projects from the center of the face modem times, rhinoplasty has and warms, filters, and moistens air developed into a high-technology on the way to the respiratory tract. procedure that combines art with Someone breathing only through the latest scientific advancements.' the mouth delivers a bolus of air During rhinoplastic procedures, with each breath. The components surgeons can change the shape and of the nose allow a thin flow of air size of the nose to improve physical to reach the lungs, which is a more appearance or breathing. From the efficient distribution of air to the central position it occupies in the lungs.' The nose consists of external face, the nose has important and internal components (Figures 1, aesthetic implications. Regardless of 2, and 3). The external nose is that how pleasing or acceptable the other portion of the nose that projects features may be, if the size and from the face and includes the nasal shape of the nose are not in bones, nasal cartilages, and connec- harmony with the rest of the face, it tive tissue covered with skin, nos- has a dominating effect. Individuals trils and tip, major alar cartilages, who have suffered trauma or who columella, septum, and ethmoid have congenital deformities that (Figures 2,3,4, and 5). The internal Figure 1. Nasal cavity. A, Naso- affect the valve functions of the nose nose, also known as the nasal cav- pharnyx; B, Hard palate; and C, have benefitted from rhinoplasty. A ity, is divided by the septum (see Ethmoid. change in the direction of air flow Figure 5).It communicates with the through the nasal passages due to nostrils and continues on to the inside the nostrils that is lined with trauma may cause metaplasia nasopharvnx. The inferior border of skin containing sebaceous glands resulting in symptoms such as diffi- the nose 15 rhe hard pnlat~,.Thc and stiff hair known as vibrissae (see is Isre cult breathing, sinus pain, headache, sun~>riurbor~ier the rthrnoid ~ Figure I)." foul odors, stuffiness, dry throat, re 1).The turbinates lie The nose contains an internal and infection, and recurrent epistaxis.' between these borders (see Figure external valve. The internal valve is The most common types of nasal 2). the caudal reflection of the upper lat- obstructions are the irregular sep- The nasal bones are two small eral cartilages and the external valve tum, hypertrophied turbinates, and bones that create the bridge of the is the lower third of the nose to the nasal polyps. Many obstructions are nose (see Figures 3,4, and 5). These nostrils' flare.' External valve airway also caused by foreign objects that bones articulate superiorly with the impairment creates a condition THE SURGICAL TECHNOLOGIST MAY 1994 ration? The nasal cavitv is lined with mucous membrane overlying periosteum and per~chondr~urnthat continues from nasopharynx through the choanae to the skin at the vestibule? The nasal fossae are the two halves of the nasal cavity, connect- ing the extemal nares with the nasopharynx by way of the funnel- like choanae? The ala nasi are the wings of the nose that form the lateral walls of Figure 2. Vertical section through the nostrils. Alaplasty is performed to reduce nostril size in this instance the nose. A, Inferior meatus; and B, Inferior turbinate. (Figures6 and 7): The turbinate bones consist of the Figure 4. Retruded columellar-labial superior middle and inferior con- angle. known as flutter valve where a chae. Grooves called nasal meatuses weak or poorly supported nostril separate the turbinate bones and nose has not yet completed growing closes or flutters on inspiration, drain the accessory sinuses (see Fig- in children and adolescents, instead of flaring the nostrils from ure 2). Communicating arteries are aesthetic surgery is not the extemal valves. The internal located beneath the epithelial layer recommended until individuals valve is created by the nasal floor, of turbinated bone? Dilation of the have reached their middle teen the septum, and the caudal reflec- su~erficialveins causes the years. The patient's general health tion of the upper lateral cartilage. It tu;binates to swell, becoming hyper- must also be reviewed in older acts paradoxically by widening on troohic and creatine" an airwav adults considering this procedure. expiration and narrowing on inspi- obstruction. Airway obstruction is Finally, the patient's mental stability relieved when the surgeon performs and expectations must be closely an inferior turbinectomy using examined and discussed prior to Takahashi or Gruenwald forceps.' undergoing surgery to ensure that The dorsum extends from the the patient does not have unrealistic radix, which is the root of the nose, expectations of the end results; the to the distal projections of the lateral attainment of physical perfection crus and the dome. The dome is the and life happiness should not be most prominent part of the alar car- among the patient's goals for plastic tilage? The area of crucial surgery? In some cases, nose shapes refinement in cosmetic surgery is represent specific ethnic heritages. the tip, defined as the left and right At times, the patient's aims may lateral projections of the dome and clash with surgical realities. When a the point from which the dorsum ends to the columellar-lobulariunc- tions? Blood is supplied to the nose by branches of the internal maxillarv artery. The maxillary branch of tke trigeminal nerve provides innerva- tion to the nose." Preoperative Considerations and Patient Selection The patient has an initial consulta- tion with the surgeon to assess the Figure 3. Side view of the nasal patient's suitability for aesthetic bones, upper lateral and alar crus. A, rhinoplasty. Among the factors the Nasal bones; B, Upper lateral cart- surgeon will use to determine J lage; C, Major alar cartilage; D, Inter- whether an individual is a good Figure 5. Side view nasal septum. A, cartilaginous incision; E, Intracarti- candidate for rhinoplasty are the Ethmoid (perpendicular plate); 8, laginous incision; and F, Infracartigi- patient's age, general health, and Septa1 cartilage; C, Alar cartilage; D, nous incision. emotional well-being.' Because the Vomer; E, Nasal bone. THE SURGICAL TECHNOLOGIST MAY 1994 patient seeks a nose shape that is an Preoperative Local Infiltration Types of Incisions unrealistic conversion, the surgeon Most commonly, a sterile medicine Most surgeons who perform rhino- will suggest a surgical plan during cup, 10-ml syringe, 27-gauge 11/4- plasty use one of three transcarti- consultation that will minimize any inch needle, 1%lidocaine with epi- laginous-vestibular incisions. An undesirable attributes while maxi- nephrine 1:100,000,3 x 3 inch gauze infracartilaginous incision is made mizing balance and harmony. strip, and small speculum are along the caudal reflection of the required? alar cartilages, whereas an intracar- Preoperative Medication and Anes- Injection begins at radix into soft tilaginous incision is made through thesia tissue, then the needle is placed in the alar cartilage (see Figure 3). An Preoperative medication may range vestibule injecting over dorsum and intercartilaginous incision is made from transdermal scopolamine along future osteotomy sites, includ- between the alar cartilages and the (Transderm Scop disc) the night ing the caudal reflections of the lat- upper lateral cartilages and entered before surgery to preoperative intra- eral crus, and the membranous sep- throueh" the vestibule of the nose venous medication. Titration is more tum to the nasal spine. The alar lob- (Figures 3 and 10). These are classi- reliable than intramuscular iniection. ules are infiltrated when alar wedge fied as closed incisi~ns.~ The patient may receive 10 mg of resections are planned and the final Open rhinoplasty may involve a diazepam 1 hour preoperatively or injection is near the infraorbital fora- transcolumellar approach using a lorazepam under the tongue a few men. Any distortion of the tip and minutes before surgery." dorsum caused by injection will diminish after skeletization. Injec- tion helps reduce bleeding during resection? Preoperative Packing The supplies and instruments gen- erally used include a sterile medi- cine cup, bayonet forceps, small nasal speculum, and 1/2-inch plain packing." Packing is dipped in a mixture of tetracaine hydrochloride or cocaine I tum, inferior turbinate, and nasal Figure 6. Alaplasty (after closure). floor. The second pack is placed on the mucosa over the lateral chevron-like incision or stepped inci- sion (Figure 11).The surgeon under- Local anesthesia with intravenous osteotomy site's dorsal area and the roof of the nasal cavity, then mines the skin using a cephalad and sedation and monitoring by the sur- lateral skeletization, enabling the geon is an accepted standard of care removed just before incision (Fig- ures 8 and 9).' underlying anatomy of the nose (many surgeons prefer general anes- (including the alar cartilages, upper thesia).