sign in sign up
<<
Home , Rhinoplasty

Butterfly in Functional Rhinoplasty

Lacie Sautter, cst

Nasal airway obstruction has numerous causes, with nasal valve disorders becoming more frequently recognized as contributors to airway obstruction.5 Nasal valve stenosis occurs when the nasal airway’s narrowest part becomes weakened causing one or both sides of the to fall into the airway when breathing in. There are different ways to repair nasal valve stenosis, and different types of grafts can be used to increase airway function. For the purpose of this article, the butterfly graft will be explored as a cosmetically pleasing and successful method of correcting this condition.

Anatomy he tip of the nose is referred to as the apex.1 The nasal sep- LEARNING O BJECTIVES tum is the that divides the nostrils, and the colu- s Review the anatomy affected by mella is the bridge of tissue that separates the nostrils at the a butterfly graft in functional nasalT base. Anteriorly, the septum is cartilaginous, and posteriorly rhinoplasty the septum has bony attachments to the ethmoid and .2 s Examine the positioning and The flared external nostrils are called the ala. The internal valve is the prep for the patient primary regulator of nasal airflow, which is situated at the narrow- est portion of the nasal airway. The area is bordered medially by the s List the instrumentation and nasal dorsal septum, laterally by the caudal edge of the upper lateral equipment used in this operation cartilage, the floor of the nose inferiorly and inferolaterally by the s Recall the procedural steps head of the inferior middle turbinate.3 The external valve of the nose involving the butterfly graft is located inside the nasal vestibule formed by the alar rim, columella s Identify the post-operative and nasal floor. The dorsum is between the root and the tip, with the complications for this procedure bridge being the upper portion of the dorsum.4 The superior, middle and inferior turbinates are located laterally on both sides of the nose, curving medially and directed downward.

MAY 2014 | The Surgical Technologist | 207 Conchal cartilage exposed showing the appropriate size of the graft Conchal ear cartilage removed from the graft site

The graft after it has been beveled, measure and trimmed of excess tissue. The graft demonstrating how it will sit inside of the nose The midline is made with a marking pen after the graft is measured

Nasal Val ve Collapse a nd Stenosis lateral and strength of tip support. Strong sur- There are two classifications of nasal valve collapse: stat- gical candidates for a primary butterfly graft report nasal ic and dynamic. Static internal nasal valve collapse is a obstruction that is relieved with either the Cottle’s maneuver narrowing of the middle third of the nose at rest,5 which or application of external nasal dilator devices.7 For the Cot- is often a result from trauma or a previous rhinoplasty. tle’s maneuver, the physician applies slight lateral traction on Patients with static internal nasal valve collapse often have the cheek next to the nose and assesses which movements weak upper lateral cartilages, thin skin and apex ptosis, during inspiration improve breathing as the lateral wall which adds to the narrowed valve angle. Dynamic nasal stiffens. To pinpoint the location of collapse, the physician valve collapse is a narrowing of the upper lateral carti- may introduce a cotton tip applicator or cerumen curette lage and middle third section that occurs with active nasal intranasally to support the internal or external nasal valve inspiration; it appears at normal size when at rest.6 This is to observe if nasal airflow symptoms improve.8 The precise commonly a result from nasal muscle deficiency that can location of the valve collapse is noted for . The sur- result in sidewall weakness. geon also will assess the condition of the patient’s septum and inferior turbinates. Examination The patient will need to answer a series of questions dur- The patient will need to consult with a facial plastic sur- ing their initial clinic visit including: geon so the doctor may inspect the patient’s nose for • History of nasal trauma? If so, when? strength and length of the nasal bones, upper and lower • Is there a history of seasonal allergies? (Allergies are

208 | The Surgical Technologist | MAY 2014 The nose retracted to shown graft placement, special attention to the midline mark on the graft to show symmetry

Since the nose is an airway passage, this treated non-surgically.) • Is breathing on one side of the nose better or worse? case is considered a clean, not sterile, pro- • Have nasal sprays and/or nasal salines helped alleviate symptoms? cedure. The patient is positioned supine • Is there a history of previous nasal or sinonasal surgery? on the OR table with the arms tucked at the • Have the use of breathe aide strips helped to alleviate conditions? sides, or Fowlers position with the hands Photos and X-rays of the patient’s will be taken at the various body planes to provide the references placed in the lap. The OR table may need to to symmetry, alignment and cosmetic aspects of the exterior nose and nasal cavity prior to the procedure. be turned to facilitate the surgeon’s access to the operative site. Equipment, Instruments, Supplies, and Medications The equipment needed for a rhinoplasty includes head- light for the surgeon, electrosurgical unit (ESU) set at 18 for coagulation, and suction. Instrumentation needed for

MAY 2014 | The Surgical Technologist | 209 Specifically designed for a variety cases

Spreader Grafts the procedure is a rhinoplasty or basic nasal instrument set that includes a Frazier suction tip. Needed supplies are: Another commonly performed technique to increase patient donut headrest; sterile skin marking pen; cotton-tip nasal airway function and correct nasal valve col- applicators; plastic/facial back table custom pack; 4 x 4 radi- lapse, is the use of spreader grafts. Spreader grafts opaque sponges; #15 knife blades x 3; suction tubing; ear Maximize Space syringe; sterile gown and gloves; needle tip for ESU pencil; are 3x20-mm cartilaginous grafts used to reposition With our two-tier back table 4-0 or 5-0 plain gut suture on double-armed Keith needle; the upper lateral cartilages and maintain middle nasal and drape, create one sterile field 4-0 nylon suture; 4-0 polyglactin 910 suture; 5-0 polydioxa- with multiple levels to increase vault width. The cartilage is taken from the septum none (PDS® II) suture; 5-0 Chromic gut suture; 6-0 plain gut your usable work space. and prepared into two long thin pieces to be placed suture; nasal splint; and cotton bandages. Warm saline will along the nasal dorsum in a subsuperficial musculo- be needed for irrigation purposes. Additionally, the CST Drape aponeurotic system plane and sutured to the upper should confirm the patient photos and X-rays are available Create a sterile field with in the OR. lateral cartilages as a stent to open the nasal valves. our standard or heavy-duty one- Spreader grafts are preferred over the butterfly graft piece patented drape. Clear if the patient has an extremely crooked nose because plastic window in rear allows for Prior to the start of the procedure, the surgeon will inject light penetration and improved the spreader graft provides better stability after the ; even when general anesthesia is visibility. bony work to straighten the nose than the butterfly planned the local and topical anesthetics are administered Protected by U.S. Patent No. 6,019,102 graft. The spreader grafts displace the upper lateral to aid in hemostasis, reduce the size of the nasal mem- cartilages laterally. It is placed submucosally and is branes and aid in decreasing the immediate postoperative Visibility secured with sutures. pain. The surgeon usually administers the local and topical anesthetics prior to the skin prep and draping to allow the Arrange and organize 1. D. Heath Stacey, MD; Ted A. Cook, MD; and Benjamin C. Marcus, MD. medications to take effect; this may be performed in the trays easily - without the need for stacking. “Correction of Internal Nasal Valve Stenosis: A Single Surgeon Compari- preoperative holding area or the OR. The supplies and drugs son of Butterfly VersusT raditional Spreader Grafts.” Annals of Plastic needed are a Mayo stand, nasal speculum, Bayonet forceps, Surgery 63.3 (2009): 280. Print. local anesthetic with epinephrine (usually 1% ), 2. D. Heath Stacey, MD; Ted A. Cook, MD; and Benjamin C. Marcus, MD. Time “Correction of Internal Nasal Valve Stenosis: A Single Surgeon Compari- 10-mL Luer-Lok syringe with 25-gauge needle, crystallized Improve setup efficiency son of Butterfly VersusT raditional Spreader Grafts.” Annals of Plastic or oxymetazoline (used as a decongestant), ½” x 3” and workflow during large surgical Surgery 63.3 (2009): 280. Print. cottonoid sponges, cups, and cotton-tipped appli- cases. 3. D. Heath Stacey, MD; Ted A. Cook, MD; and Benjamin C. Marcus, MD. cator. The surgeon injects the local anesthetic into the nose “Correction of Internal Nasal Valve Stenosis: A Single Surgeon Compari- and turbinates, and inserts two cocaine or oxymetazoline son of Butterfly VersusT raditional Spreader Grafts.” Annals of Plastic soaked cottonoid sponges in each nostril. Surgery 63.3 (2009): 282. Print.

Positioning, Skin Prep a nd D raping BIG CASE Back Tables Since the nose is an airway passage, this case is considered a clean, not sterile, procedure. The patient is positioned Set at 15" above main surface When preparing the graft site, a conservative dor- supine on the OR table with the arms tucked at the sides, Set at 12" above main surface sal reduction is performed to create room for the or Fowler’s position with the hands placed in the lap. The OR table may need to be turned to facilitate the surgeon’s graft and ensure an aesthetically pleasing nasal access to the operative site. Since a graft will be taken from the concha of the ear, general anesthesia is administered. dorsum. The butterfly graft is placed in a pocket at For this case, skin prep was ordered with both the patient’s 38" max. height the caudal end of the upper lateral cartilages and face and prepped with a povidone-iodine solution. (Skin prep for this procedure may vary. Follow your facilities’ pro- 29" min. height deep to the cephalic border of the lateral crura. tocol.) The draping will consist of a half sheet folded with a towel under the head forming a turban. It will be secured with a penetrating towel clip, and a towel will be placed over Table has a 9" vertical travel to reach a maximum 210 | The Surgical Technologist | MAY 2014 height of 38". TEL 800.937.7949 • 4000 SE Columbia Way • Vancouver, WA 98661 the endotracheal tube followed by a split drape or U-drape, used to control bleeding and a 4-0 or 5-0 fast-absorbing leaving both exposed. In the instance that the left ear suture (surgeon’s preference) is used to close the incision. cartilage is suboptimal for the butterfly graft, or the patient A dressing bolster is placed in the concha of the ear and has had a previous graft taken from the left concha, the behind the ear, and is secured with a 4-0 nylon suture to right ear may be used. prevent a . Once the conchal cartilage is removed, the surgeon mea- Surgical Procedure sures the graft and draws a line directly down the center Using the Bayonet forceps, the surgeon removes the cot- of the graft with a sterile marking pen and ruler to ensure tonoid sponges, and using a sterile skin pen marks an accurate graft placement. The surgeon prepares the graft by “inverted V” incision on the columella. With a #15 blade thinning it with a #15 knife blade. Beveling the edges will and a wide double-skin hook, the surgeon makes the ini- ensure a smooth dorsal contour.9 When preparing the graft tial incision as well as intercartilaginous incisions on the site, a conservative dorsal reduction is performed to create inside of both nostrils followed by the hemitransfixion inci- room for the graft and ensure an aesthetically pleasing nasal sion. Using Iris scissors and switching to a small double- dorsum.10 The butterfly graft is placed in a pocket at the skin hook placed at the apex of the nose for exposure, the caudal end of the upper lateral cartilages and deep to the surgeon combines the incisions. Using a combination of cephalic border of the lateral crura. The converse retractor Iris scissors and skin hooks to gain exposure, the surgeon is placed to hold up the pocket and the graft is inserted with dissects down to the upper lateral cartilages and the sep- tum. Once the have been exposed, the sur- Once the surgeon assesses the available cartilage geon dissects the septum. A #15 blade will be used to score the cartilage, and a Freer elevator will be used to raise the from the septum and the cosmetic adjustments that mucoperichondral flap. A narrow Cottle nasal speculum is used to expose the septal cartilage and the will will be made to the nose, the harvesting of the con- begin by using the Freer and the Cottle to loosen the sep- chal cartilage from the left ear will begin. If the tum from the mucoperichondral flap. The Takahashi forceps is used to remove deviated portions of and cartilage. patient has a crooked nose or has previously broken The surgical technologist needs to save the septal cartilage in a saline-filled medicine cup for possible graft use later. his or her nose, an osteotomy may be performed to Once the surgeon assesses the available cartilage from the refracture the bones in order to straighten them. septum and the cosmetic adjustments that will be made to the nose, the harvesting of the conchal cartilage from the left ear will begin. If the patient has a crooked nose or has previously broken his or her nose, an osteotomy may be a smooth Adson-Brown forceps. The graft is secured with a performed to refracture the bones in order to straighten 5-0 polydioxanone suture.11 them. Frequently, especially in patients with thin skin, crushed Using the sterile skin marker, an anterior helical rim cartilage grafts are placed on the nasal dorsum, cephalic to incision is outlined in order to take a graft measuring 1 x the upper edge of the butterfly graft, in order to camou- 2 cm from the lateral flat portion of the concha of the ear.9 flage the graft edges and create a smooth dorsal contour.12 The incision is made with a #15 knife blade, and tenotomy After the graft is placed, the surgeon begins closure of the scissors are used to undermine the skin and expose the nose. The anterior septum is closed with a 4-0 plain gut on conchal cartilage. Cotton-tipped applicators are utilized to a double-armed Keith needle, which is useful if a strut graft push back the mucosa to expose the right plane to minimize is placed for stability of the columella. A 4-0 polyglactin bleeding. The conchal cartilage is incised with a #15 knife 910 quilting stitch is used to close the septum. The surgeon blade. The tenotomy scissors with cotton-tipped applica- uses a 6-0 fast absorbing plain gut to close the columel- tors are used to undermine the cartilage and completely lar incision and a 5-0 chromic gut on a 1/2-inch reverse remove it from the ear. The ESU pencil with needle tip is cutting needle for the marginal incisions inside the nose.

212 | The Surgical Technologist | MAY 2014 Two pieces of rolled up bandages are placed in both nostrils 3. “Anatomy of the Nose and Sinuses.” Surgical Technology for the Surgi- to control bleeding. The surgeon places paper tape over the cal Technologist. Ed. Kevin B. Frey, CST, MA and Tracy Ross, CST, M.Ed. Clifton Park, NY: Delmar Cengage Learning, 2008. 632. Print. nose as a soft splint. If bone work or osteotomies were per- 4. “Anatomy of the Nose and Sinuses.” Surgical Technology for the Surgi- formed, a cast dressing is placed on the nose. cal Technologist: A Positive Care Approach. Ed. Kevin B. Frey, CST, MA and Tracy Ross, CST, M.Ed. Clifton Park, NY: Delmar Cengage Learning, 2008. 632. Print. Post-Operative Considerations 5. “Anatomy of the Nose and Sinuses.” Surgical Technology for the Surgi- After the patient is awake and extubated, he or she are trans- cal Technologist. Ed. Kevin B. Frey, CST, MA and Tracy Ross, CST, M.Ed. Clifton Park, NY: Delmar Cengage Learning, 2008. 632. Print. ported to the PACU with the head of the stretcher elevated. 6. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly The CST should not break down the back table or Mayo Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009): 259. Print. stand until the patient is transported out of the OR. The 7. “Anatomy of the Nose and Sinuses.” Surgical Technology for the Surgi- bandage rolls are removed in the PACU, and the patient is cal Technologist. Ed. Kevin B. Frey, CST, MA and Tracy Ross, CST, M.Ed. released once he or she is awake and minimal to no bleeding Clifton Park, NY: Delmar Cengage Learning, 2008. 632. Print. 8. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly is documented. Bruising, swelling and minimal bleeding are Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009): common side effects. It is not uncommon for the patient to 260. Print. 9. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly have orbital bruising if osteotomies were performed. Patient Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009): discharge instructions include gently applying a small ice 260. Print. pack to the nose to aid in reducing swelling and pain, to 10. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009): remain in bed for the first post-operative day with his or 255. Print. her head elevated and to take oral . The patient 11. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009): is instructed to not blow the nose and avoid vigorous face- 260. Print. washing for one week. The main concern is significant bleed- 12. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly ing, in which the surgeon may need to place nasal packing, Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009): 258. Print. or in a worse-case scenario, return the patient to surgery to 13. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly cauterize or place another suture. Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009): 259. Print. Photos courtesy of Tom D Wang, MD, and Adam Terella, 14. D. Heath Stacey, MD; Ted A. Cook, MD; and Benjamin C. Marcus, MD. MD. Special thanks to Dr Wang and Sachin S Pawar, MD. “Correction of Internal Nasal Valve Stenosis: A Single Surgeon Compari- son of Butterfly Versus Traditional Spreader Grafts.” Annals of Plastic Sur- gery 63.3 (2009): 282. Print. Author’s Bi o 15. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly Lacie Sautter, CST, lives in Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009): 259. Print. Portland, Oregon, with her husband and two dogs. She graduated from the surgical technology program at Con- corde Career College more than four years ago and cur- rently works at Oregon Health & Science University and The Portland Clinic where she pri- marily scrubs ENT.

References 1. Oren Friedman, MD; and Ted A. Cook, MD. “Conchal Cartilage Butterfly Graft in Primary Functional Rhinoplasty.” The Laryngoscope 119 (2009): 255-262. Print. 2. D. Heath Stacey, MD; Ted A. Cook, MD; and Benjamin C. Marcus, MD. “Correction of Internal Nasal Valve Stenosis: A Single Surgeon Comparison of Butterfly Versus Traditional Spreader Grafts.” Annals of 63.3 (2009): 280-283. Print.

MAY 2014 | The Surgical Technologist | 213 ButterflyG raft in Functional Rhinoplasty CE EXAM 365 MAY 2014 1 CE credit - $6

1. The external valve of the nose is 4. The patient is positioned ____ on the 8. Along with a #15 knife blade, ______located inside the nasal vestibule OR table with the arms tucked at the are used to undermine the skin and formed by the alar rim, ______and sides, or Fowler’s position with the expose the conchal cartilage. nasal floor. hands placed in the lap. a. Tenotomy scissors a. Dorsum c. Columella a. Lateral c. Prone b. Bayonet scissors b. Ala d. Vomer b. Supine d. Kraske c. Cottle septum scissors d. Goldman septum scissors 2. Dynamic nasal valve collapse is the 5. The ______forceps is used to narrowing of the _____ and _____ remove deviated portions of bone and 9. If osteotomies were performed, it is that occurs with active nasal inspira- cartilage. not uncommon for the patient to have tion. a. Bayonet ______. a. Upper lateral cartilage and middle b. Knight a. Swelling third section c. Adson-Brown b. Bruising b. Lower lateral cartilage and middle d. Takahaski c. Bleeding third section d. Limited eyesight c. Upper lateral cartilage and middle 6. Using a sterile skin pen , the surgeon second section marks an inverted V on the ______. 10. There are two classifications of nasal d. Lower lateral cartilage and middle a. Nasal base valve collapse: static and dynamic. first section b. Nasal floor Static internal nasal valve collapse is c. Caudal edge a narrowing of the ______of the 3. For patients with thin skin, crushed d. Columella nose at rest. cartilage grafts are placed on the a. Lower third ______, cephalic to the upper 7. A narrow Cottle ______is used to b. Lower second edge of the butterfly graft. expose the septal cartilage and the sep- c. Middle third a. Upper lateral cartilages toplasty will begin. d. Upper third b. Conchal cartilage a. Chisel c. Nasal Dorsum b. Nasal speculum d. Septum c. Mallet d. Cartilage crusher

Butterfly Graft in Functional Rhinoplasty 365 MAY 2014 1 CE credit - $6 Make It Easy - Take CE Exams Online NBSTSA Certification No. a b c d a b c d AST Member No. 1 ■ ■ ■ ■ 11 You■ must ■have a■ credit■ card to ■ My address has changed. The address below is the new address. 2 ■ ■ ■ ■ 12 purchase■ test■ online.■ We■ accept Visa, MasterCard and American Name 3 ■ ■ ■ ■ 13 ■ ■ ■ ■ Express. Your credit card will Address 4 ■ ■ ■ ■ 14 only■ be charged■ ■ once ■you pass ■ ■ ■ ■ ■ ■ ■ ■ City State Zip 5 15 the test and then your credits will be automatically recorded Telephone 6 ■ ■ ■ ■ 16 ■ ■ ■ ■ 7 ■ ■ ■ ■ 17 to your■ account.■ ■ ■ ■ Check enclosed ■ Check Number Log on to your account on 8 ■ ■ ■ ■ 18 ■ ■ ■ ■ ■ Visa ■ MasterCard ■ American Express the AST homepage to take 9 ■ ■ ■ ■ 19 ■ ■ ■ ■ Credit Card Number advantage of this benefit. 10 ■ ■ ■ ■ 20 ■ ■ ■ ■ Expiration Date

214 | The Surgical Technologist | MAY 2014 ButterflyG raft in Functional Rhinoplasty CE EXAM Studying for the CST Exam? There’s an App Earn CE Credits at Home You will be awarded continuing educa- tion (CE) credits toward your recertifica- for That tion after reading the designated arti- cle and completing the test with a score of 70% or better. If you do not pass the test, it The only AST-authored study will be returned along with your payment. guide with more than 1,400 Send the original answer sheet from the questions has gone mobile! journal and make a copy for your records. If AST recently published its first possible use a credit card (debit or credit) for app – AST Study Guide – and it’s payment. It is a faster option for processing of available in the iTunes Store and credits and offers more flexibility for correct Google Play. payment. When submitting multiple tests, you do not need to submit a separate check The app includes six tests to for each journal test. You may submit multiple review and utilize while journal tests with one check or money order. preparing for the CST Members this test is also available online examination sponsored by the at www.ast.org. No stamps or checks and it National Board of Surgical posts to your record automatically! Technology and Surgical Assisting. Now, all the study Members: $6 per credit tips are conveniently in the (per credit not per test) palm of your hand. Nonmembers: $10 per credit (per credit not per test plus the $400 nonmember Study with confidence fee per submission) whenever and wherever you are! After your credits are processed, A ST will send you a letter acknowledging the number of credits that were accepted. Members can also check your CE credit status online with your login information at www.ast.org. 3 O WAys T SUBMIT YOUR CE CREDITS Mail to: AST, Member Services, 6 West Dry Creek Circle Ste 200, Littleton, CO 80120-8031 Fax CE credits to: 303-694-9169 E-mail scanned CE credits in PDF format to: [email protected] For questions please contact Member Services - [email protected] or 800-637-7433, option 3. Business hours: Mon-Fri, 8:00a.m. - 4:30 p.m., MT

MAY 2014 | The Surgical Technologist | 215