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Rhinoplasty ARTICLE by PHILIP WILKES, CST/CFA

Rhinoplasty ARTICLE by PHILIP WILKES, CST/CFA

ARTICLE BY PHILIP WILKES, CST/CFA

hinoplasty is plastic become lodged in children's .3 , laterally with the , of the 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 ? metic purposes. The natives. The 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 (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 . tal and vomeronasal . 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 modem times, rhinoplasty has and warms, filters, and moistens air developed into a high-technology on the way to the . procedure that combines art with Someone only through the latest scientific advancements.' the mouth delivers a bolus of air During rhinoplastic procedures, with each breath. The components can change the shape and of the nose allow a thin flow of air size of the nose to improve physical to reach the , 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, , and connec- harmony with the rest of the face, it tive tissue covered with , 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. . A, Naso- affect the valve functions of the nose nose, also known as the nasal cav- pharnyx; B, Hard ; 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 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 , stuffiness, dry throat, re 1).The turbinates lie The nose contains an internal and , 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 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 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 . 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 performs and expectations must be closely an inferior 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? is supplied to the nose by branches of the internal maxillarv artery. The maxillary branch of tke trigeminal 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, .

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 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% 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

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 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). A surgeon using intravenous laterals, and nasal bones) to be sedatibn maybrefer thppatient be at Patient Preparation The surgeon may prep the vestibule undraped and fully exposed.' his or her deepest level of sedation Surgeons disagree on whether the during the initial preparatory injec- to the internal valve by shaving the vibrissae and swabbing the area use of closed or open rhinoplasty is tion and packing of the nose, and preferable. Jack H. Sheen, MD, during fracture and osteotomy. Intra- with povidone iodine. Some surgeons consider the vestibule of states, "Never make an external inci- venous sedatives of choice are typi- sion when an internal one will do." cally a combination of thiopental the nose to be a "dirty" area, and believe that extensive preparation A transcolumellar incision is sodium, fentanyl citrate, diazepam, unacceptable, according to Sheen.' and midazolam. A 0.2 saturation is has no effecton the surgical outcome! A normal external skin However, rhinoplasty specialist maintained by oral catheter! Lawrence Birnbaum, MD, believes The surgeon may opt for general prep is required in all situations. Typically, the face and submental that, "The optimum exposure offered anesthesia when performing more by the open approach reduces the substantial cases, which require the area below the chin is washed with hexachlorophene and sterile water likelihood of touch-up revisions and services of an anesthesiologist or the scarring is minimal."vFor the anesthetist. The anesthesiologist may and blotted dry with sterile gauze. A head-drape, towels, and split- purposes of this article, the open choose to use isoflurane. Enflurane is approach will be assumed. preferred by some surgeons since it sheet are used in rhinoplastic proce- dures. reduces cardiac irritability by lower- and Submucous Resec- ing blood pressure allowing a greater tion use of epinephrine! Septoplasty is the surgical I

THE SURGICAL TECHNOLOGIST MAY 1994 has been removed, the surgeon may reduce the dorsum with a rasp and , then replace the original portion of dorsum that may also have been reduced to recreate the roof (see Figure 8). Lateral osteotomies are accom- plished through stab in the posterior area of the left and right vestibules. Incisions are made near the pyriform aperture to the bone. A Joseph periosteal elevator is then used to raise the periosteum prior to posting osteotomes or saws. Saws or osteotomes are inserted in a cepha- lad direction.' If osteotomes are used, the sur-

L geon will hold and direct the Figure 8. Nasal vault. A, Roof off nasal vault (trim and replace); B, Nasal vault, osteotome with one hand while hump rasped or shaved (roof intact); C, Nasal vault, roof removed lateral positioning the fingers of the other osteotomies performed, and roof reformed. hand to determine when the osteotomy is complete. Since the surgeon is using both hands at this time, the assistant is responsible for reconstruction of the nasal septum. partial-depth cuts (Figure 13).A the appropriate blows with the mal- Submucous resection involves the narrower tip with more projection is let to the head of the osteotome, excision of part of the deviated sep- produced, converting a box shape under complete supervision of the tum. A flap of mucous membrane is into a triangular one. Morselization surgeon. The surgeon will direct the first layed back and replaced or of the dome, a procedure in which first assistant with phrases such as, repositioned following the opera- an instrument called the morselizer "tap-tap," or "tap," or "too hard," or tion.lUAfractured or deviated nasal with opposing interlocking teeth is "a little harder." The assistant must septum results in reduced drainage used to take the stiffness out of car- be sensitive to the tone and inflec- and respiratory functions. Devia- tilage, is not recommended. tion of the surgeon's verbal tions of cartilage and bone compress Alaplasty may also be part of the commands and strive to echo these the turbinates, causing blockage of surgical plan for partial rhinoplasty. commands with physical action. The the sinus openings. The surgeon In addition, a retrolabial-columellar blow struck must be a clean one, not will remove the offending obstruc- may be inserted using alar car- a push or a glancing blow. There is a tions and re-establish a partition tilage sutured together in a layered sound and feel that the mallet oper- between the right and left nasal cav- fashion to reduce a sharp retrolabial ator should develop. Earlier blows ities by performing a septoplasty or angle (Figures 4 and 9). The alar a submucous resection.' grafts are stacked with convex sides facing outward. Partial Rhinoplasty A partial rhinoplasty includes pro- Complete Rhinoplasty cedures such as when a surgeon A complete rhinoplasty is an exten- rasps the dorsum, reduces the sion of the partial rhinoplasty except cephalic portions of the alar crus, when the dorsum or hump is and undermines the skin over the reduced. The dorsum includes the dome (see Figure Q2Usingthe anterior portion of the bony vault eversion or retrograde technique, an and the anterior septum. A intercartilaginous incision is made complete rhinoplasty is equivalent with scissors placed retrograde and to removing the roof of a rectangu- the lateral crus is exposed and lar pyramid (see Figure 8).If the trimmed (Figure 12). The cartilage is base of the pyramid is too wide, it exposed by eversion and excised, can be narrowed by performing allowing the tip to rotate upward. A osteotomies on its lower lateral sur- transfixion incision is normally not . The anterior portions of these Figure 9. Columellar-labial angle made for a partial rhinoplasty. now detached walls are then joined repaired. A, Symbol for bony carti- Another example of a partial rhino- to reform the roof of the pyramid. If laginous vault; B, Alar grafts in plasty involves the weakening of the osteotomies to narrow the base are pocket behind columellar-labial dome cartilage by interdigitating not necessary, yet the dorsum roof angle.

THE SURGICAL TECHNOLOGIST MAY 1994 maintaining the original character.' Finesse rhinoplasty requires the application of any or all of the regu- lar surgical steps associated with rhinoplasty in minimal degrees.

Specimen and Tissue Handling Tissue taken from the nose must be handled carefully and kept molst- rnrd tvith salini, solution.' Sental cartilage should be kept sepa;ately I I in a medicine cup or on a wet sponge, sheen grid, or tongue blade. Figure 12. Eversion/retrograde tech- Septal cartilage may be the first tis- nique. sue removed and is returned just prior to closure. Turb'inate and sep- days. A vestibular area pack is used tal tissue must be saved in case it is to aid in tissue approximation (24 Figure 10. Vestibular incision. necessary to prove that the nasal hours). For septal surgery a surgeon surgery was performed for more may also use plastic splints sutured are rcwnant and pcnerratlng, while than cosmetic purposes. on each side of the septum using a the, tinal blon ten& to be sol~d. through-and-through stitch, or mag- resistant, and nonresonant. Grafts nets can be used to help in septal The most common sources of graft approximation and to reduce Finesse Rhinoplasty material for reconstructive purposes . These internal splints The term "finesse rhinoplasty" was are the alar crura, septal cartilage, will be removed later with packs.'.9 coined by Sheen in his book, Aes- and the concha. Alternative Tincture of benzoin may be used thetic Rhinoplasty.' Finesse sources include the ethmoid/ externally over the bridge of the rhinoplasty has been performed by vomer, cranial bone, and rib. The nose and on the malar area. Paper many surgeons in the past and con- ninth rib could be called the nose rib tape in layers is applied to prepare tinues to grow in popularity among because crushed portions of it can the area for either a plaster or plastic surgeons. Finesse rhinoplasty is be contoured for use in the splint or a second layer of tape described by Sheen as "making columella, tip, maxilla, and dorsum. splint. A V-notched piece of tape something subtle out of something The seventh, eighth, and tenth ribs will be used across the columella to complex." Patients who want a are also usable as grafts.' help sling and form the tip. This is finesse rhinoplasty are looking for followed by a drip sponge dressing. super-refinement. This could Postoperative Care A partial rhinoplasty may require involve reduction in size of an oth- Generally, if no septal or turbinate only tape, while a complete rhino- erwise perfect nose or subtle tip surgery has been done, little or no plasty requires tape, splint, packs, refinement. packing is used. If a septoplasty or a and drip sponge. A finesse rhino- The attitude toward finesse turbinectomy has been performed, plasty may require either tape only rhinoplasty as described by Sheen is applied dressings should absorb or tape, splint, packs, and a drip one of restraint because the surgeon secretions, stop bleeding, discour- sponge.' is frequently dealing with a well- The patient's head must be kept age.. adhesions, and assist nasal balanced nose that requires reduc- hygic'nr. 'The surgt,on rnq use a elevated and ice compresses should tion in all of its dimensions while pclrolaturn g~uzc~pack for 3 to 7 be applied on and off for 48 hours. Expect oozing for 24 to 48 hours, bruising for 1to 2 weeks, and swelling for at least 6 weeks follow- ing the procedure. A degree of swelling may be evident for 1year. Vestibular packs are removed 24 hours after surgery. Septal picks and snlints arc, remuvrd in ito 7 dayshepatient should not blow his or her nose for 1month.'

Postoperative Complications Over-resection can result in postop- erative valve complications. Vestibular stenosis in another post- operative consideration. An Figure 11. Open incisions. A, Chevron-like; and B,Stepped

MAY 1994 estimated 30%of rhinoplasty patients have some vestibular reduction due to synechiae follow- ing surgery? Postoperative infection is uncom- mon in aesthetic rhinoplasty; how- ever, patients with poor healing may require a second procedure. The risk of is greatly reduced when patients follow the surgeon's instructions for postoper- ative care during the recovery period.' Figure 13.Partial rhinoplasty. A, Weakening of dome to produce higher angle; First Assistant's Role and B. Dome before partial-depth incisions. Surgical technologists who assist in a rhinoplasty procedure should be but he or she may be called upon to One of the most important tools concerned with basic scrub consid- retract with one hand while stabiliz- that a surgical technologist must erations and also mindful of the ing a tip graft or suction with the have to function effectively as a first pulse oximeter, blood pressure other hand. assistant is excellent observation. monitor, and ECG during the case. Surgical technologists must antic- While the CST/CFA does not have The assistant should also read the ipate as many of the surgeon's the benefit of medical school, a sec- chart for information regarding the needs as possible in the set-up but ond set of eyes alert for irregulari- surgeon's intentions. Check the sur- should limit the mayo tray to the ties or red flags is a great asset to the gical history and look at computer essentials. When the surgical tech- surgeon and the patient. For exam- images, photos, and x-ray film. Sur- nologist is holding retractors and ple, during the skeletization of an gical technologists who are involved the surgeon is getting his or her own area the surgical technologist's view in admitting the patient must check instruments, the instruments may enables him or her to see if the dis- that all the necessary paperwork is not be replaced in an orderly fash- section is getting very thin. In such a in order including the surgical, ion, yet the surgical technologist situation, it is the surgical technolo- anesthesia, and specialized consent must be able to find the instruments gist's responsibility to make a cau- forms, patient history and physical that the surgeon requests immedi- tionary remark; it could prevent an reports, preoperative question- ately. A magnetic instrument pad unwanted "button-hole" or iatro- naires, lab results, lab and recovery helps to organize in these circum- genic cut or tear from the undersur- room records, and postoperative stances and serves as a second or face through the skin. The surgical instructions. All of these items pro- immediate needs mayo. Once the technologist may see bleeding vide crucial information. The case begins, the priority shifts to points in the gutter of a that patient must also be scheduled for a assisting. The surgical technologist are difficultfor the surgeon to see. It follow-up appointment. must carefully choose opportunities is better to make an intervening An increasing reality in surgery to regroup the scrub needs such as statement that may prove unneces- today is that there are often three tray organization, specimen sary than to remain silent and find job roles that need to be filled (the handling, and suture preparation. that you have made a costly omis- surgeon, scrub, and the assistant) Surgical technologists should sion. and only two individuals to carry always check the suction prior to In considering the synchroniza- them out: the surgeon and the surgi- each case. Nasal are very tion of the scrub and assistant roles, cal technologist who functions as suction dependent. It is advisable to the author can best express it as fol- the scrub and first assistant. In plas- have two Frazier suction tips and lows: When you sing, sing like tic surgery offices and surgicenters, one stylet on the field at all times. If Pavarotti; when you play piano, the added demand is the ability to a tip gets clogged with bone, the play like Horowitz. But on days work fromboth sides of the table. flow of the case can be maintained when you must play and sing, think On many occasions surgical technol- with a quick tip change. It is essen- of Billy Joel or Ray Charles; they get ogists must assist with one hand tial that there be a working suction along nicely blending two jobs. and control the instrumentation at all times. The suction will alter- with the other. For those who are nately be used by the surgical tech- Summary not ambidextrous, it is helpful to nologist and the surgeon through- Rhinoplasty is a vast surgical spe- become comfortable with using the out the case during septoplasty, tur- cialty that includes many less-favored hand outside of binectomy, osteotomy, skeletization, procedures in addition to those dis- surgery, such as when eating or and closure and dressing applica- cussed in this article. Although each drinking. Rhinoplasty does not nor- tions. The surgical technologist (Continued on page 33) mally require a surgical technologist must learn to sweep with the suc- to work from both sides of the table, tion tip to get it in and out quickly.

THE SURGICAL TECHNOLOGIST MAY 1994

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