prof. dr. usama mohamed abdel naseer prof. dr....

Dorsal L-Strut Cutting and Suture Technique for correction of deviated nasal cartilaginous dorsum

Thesis Submitted for Partial Fulfillment of M.D. degree in Otorhinolaryngology

By:

Ahmed Fathy Mohamed Eldehn (M.Sc. E.N.T. Cairo University)

Supervised by:

Prof. Dr. Usama Mohamed Abdel Naseer Professor of Otorhinolaryngology

Faculty of Medicine Cairo University

Prof. Dr. Hassan Mohamed Hassan El Hoshy Professor of Otorhinolaryngology


Dr. Ahmed Mohamed Nassar Lecturer of Otorhinolaryngology



2014

Abstract A deviated nose with involvement of a severely deviated cartilaginous

dorsum is a particular challenge for rhinoplasty surgeons. We used a new approach

for treating such cases, the “dorsal L-strut cutting and suture technique,” and

assessed its efficacy and the surgical outcomes. The study population consisted of

30 patients who received the “cutting and suture technique of dorsal L-strut”

through open rhinoplasty with spreader graft insertion to control a severe

cartilaginous dorsal deflection and compared with another 30 patients treated with

spreader graft insertion only. Preoperative and postoperative photographs were

studied to evaluate outcomes. Postoperative complications were assessed. The

dorsal L-strut cutting and suture technique appears to be a useful method for

correcting severe cephalocaudal convexity of the dorsal L-strut in deviated noses.

Key Words: Rhinoplasty, septoplasty, L-strut, deviated nose, crooked nose.

ACKNOWLEDGEMENTS

I would like to acknowledge and extend my heartfelt gratitude to the following persons who have made the completion of this work possible.

This work would not have been possible without the help, support and patience of my principal supervisor, Prof. Dr. Usama Mohamed Abdel Naseer, Professor of Otolaryngology, Faculty of Medicine, Cairo University, not to mention his advice, vital encouragement and support.

The good advice, support and friendship of my second supervisor, Prof. Dr. Hassan Mohamed El Hoshy, Professor of Otolaryngology, Faculty of Medicine, Cairo University, has been valuable on both an academic and a personal level, for which I am extremely grateful.

Many thanks for my third supervisor, Dr. Ahmed Mohamed Nassar, Lecturer of Otolaryngology, Faculty of Medicine, Cairo University, for his understanding, assistance and expert guidance.

Also my parents that have given me their obvious support and love throughout my life for which my mere expression of thanks does not suffice.

I also thank all my professors in the Otolaryngology Department, Faculty of Medicine, Cairo University, for their support and assistance since the start of my residency in 2006.

Last, but by no means least, I would like to thank my colleagues and my friends for their kindness, friendship, encouragement and support.

Contents

Introduction 1 The Aim of Work 4 Review of Litreture 5

Anatomy of the External Nose 5 • Muscles of the nose 6 • Arterial supply of the external nose 7 • Nerve supply of the external nose 8 • External Nasal Frame 8 • Bony Vault 9 • Cartilaginous Nasal Frame 10 • Nasal Septum 12 Physiology of The Nose 14 Pathogenesis of Nasal Deviation 17 Preoperative Assessment 22 Surgical Approaches in Rhinoplasty 36 • Closed rhinoplasty 36 • Transcartilaginous Approach 37 • Retrograde Approach 41 • Open techniques 42 • Osteotomies 45 Techniques to Correct Deviated Cartilaginous Nasal Dorsum 50 • Extracorporeal septoplasty 51 • spreader grafts 55 • The septal extension graft 58 • septal crossbar graft 59 • New Techniques for Management of the Crooked Nose 62 • Dorsal L-Strut Cutting and Suture Technique 65

Patients & Methods 66 Results 79

Discussion 103 Conclusion 114 Summary 115 References 118 Arabic summary

I

List of Figures

Number of Figure Title Page

1. Structural support of the nose. 5 2. An illustration of the nasal musculature. 7 3. Illustration of the arterial blood supply to the nose. 8 4. Illustration of the sensory innervation of the nose. 8 5. Illustration of the external nasal frame. 9 6. The keystone area. 10 7. View of the bony and cartilaginous nasal frame. 10 8. View of the cartilaginous nasal frame. 11 9. The nasal septum. 12 10. An illustration of classes of septal deviation. 18 11. An illustration of Surface markings of the face. 22 12. Soft-tissue cephalometric points. 23 13. Horizontal facial thirds. 24 14. Vertical fifths of the face. 24 15. Nasal proportions. 25 16. The Baum ratio used to calculate nasal tip projection. 25 17. The Simons ratio used to calculate nasal tip projection. 26 18. Preoperative analysis lateral view. 27 19. Basal view of the nose. 28 20. Photography views with proper lightening. 32 21. The effect of lens distortion. 33 22. The importance of head position. 34 23. Transcartilaginous Approach. 38 24. Caudal Septal Incision. 39 25. The anterior nasal spine and the chondrospinal junction are exposed 40 26. Two-tunnel approach. 40 27. The transfixion incision. 40 28. Delivery of the lower lateral cartilage using endonasal approach. 41 29. Inverted “V” columellar incision. 43 30. “Stair-shaped” columellar incision. 43 31. Exposed skeleton of the nasal pyramid. 44 32. A visible caudal part of nasal septum. 44 33. The various types of lateral osteotomies. 45 34. Webster triangle 46 35. The course of a superior oblique medial osteotomy. 47 36. Rocker deformity. 48 37. The double-level osteotomy. 49 38. Extracorporeal septoplasty. 52 39. Fixation of the reconstructed septum. 53 40. Neocaudal septum extending past the medial crura. 54

II

41. Neocaudal septum trimmed to lie flush with the medial crura. 55 42. An illustration of spreader grafts placement & fixation. 56 43. Septal deviation and its correction using a spreader graft . 57 44. The septal extension graft. 58 45. The paired spreader technique. 59 46. Correction of crooked nose using the septal crossbar graft. 60 47. Deviation of the septum and its correction with a crossbar graft. 61 48. Deviation of the septum and its correction with a crossbar graft. 61 49. The sidewall-spreading suture. 62 50. The triangular spreader graft. 63 51. The clocking sutures. 63 52. Septocolumellar sutures 64 53. Excision of a “Burow triangle” of the septal cartilage 64 54. Dorsal L-strut cutting and suture technique 65 55. Preoperative photography views 69 56. “V” Shape incision of the open approach 69 57. Exposure of the osseocartilaginous skeleton 70 58. Dissection of the septum 70 59. Sparing “L” strut of the septum 71 60. L-strut cutting and suture technique 71 61. Insertion of spreader graft 71 62. Development of edema and ecchymosis in the postoperative period 77 63. Postoperative follow up photography 77 64. photographic assessment and patient satisfaction in group A. 81 65. photographic assessment and patient satisfaction in group B. 83 66. Comparison between both groups regarding sex. 84 67. Comparison between both groups regarding age. 84 68. Comparison between both groups regarding visual analogue scale. 85 69. Comparison between both groups regarding photographic assessment. 86 70. Female patient 28 years old with no history of trauma. 87 71. Male patient 22 years old with history of trauma. 88 72. Male patient 19 years old athletic with history of trauma. 89 73. Male patient 24 years old with history of trauma. 90 74. Male patient 34 years old with no history of trauma. 91 75. Male patient 36 years old with history of trauma. 92 76. Male patient 22 years old with no history of trauma. 93 77. Male patient 26 years old with no history of trauma. 94 78. Male patient 20 years old with no history of trauma. 95 79. Female patient 37 years old with no history of trauma. 96 80. Male patient 25 years old with history of trauma. 97 81. Male patient 42 years old with history of trauma. 98 82. Male patient 21 years old boxer with history of trauma. 99 83. Male patient 23 years old with history of trauma. 100 84. Male patient 23 years old with history of trauma. 101 85. Female patient 45 years old with history of trauma. 102

III

List of Tables Number of Table Title Page

1. Signs suspecting psychological problems. 29 2. complications with osteotomies. 49 3. History and examination sheet. 68 4. The operative data sheet. 72 5. postoperative instructions. 73 6. postoperative instructions in arabic. 75 7. age range in group A. 79 8. history and examination in group A. 80 9. photographic assessment and patient satisfaction in group A. 81 10. age range in group B. 82 11. photographic assessment and patient satisfaction in group B. 83 12. both groups regarding demographics is statistically insignificant. 84 13. Comparison between both groups regarding VAS & photograph. 86

IV

Introduction

Introduction

The septum constitutes the main central support for the nose. The most

anterocaudal portion of the septal cartilage rests on the maxillary crest in a tongue

and groove relationship. This relationship between the cartilage and the bone

renders this portion of the septum susceptible to post traumatic displacement of the

cartilage from the groove of the crest (Mendelsohn, 2005).

The area at the junction between the cephalic upper lateral cartilages and the

nasal bones, which makes up the keystone area, is characterized by a firm

adherence between these structures. Trauma to the nasal bones can shift this entire

unit. A longstanding shift of the midline structures cannot be simply corrected with

an osteotomy. It requires separation and realignment of all the structures

individually including the nasal bones, the septum and the upper lateral cartilages.

(Gubisch, 2005)

Patients with external nasal deformities frequently experience progressive

nasal obstruction. Offending trauma leads to both septal deviation and disruption

of traditional nasal support mechanisms. With loss of nasal support, internal and

external nasal valves collapse may result (Kim and Toriumi, 2004).

The deviated dorsum may create functional and aesthetic issues that require

correction. It is a complex three dimensional structure in which correcting a

functional issue may have an impact on cosmoses and cosmetic correction may

impair nasal function. Therefore, any attempt at straightening the dorsum should

achieve cosmetic outcome and maintain or improve nasal function. A proper

skeletal support is necessary to provide long term aesthetic and functional results.

(Gunther and Rorich, 1988)

1

Introduction

In the past, rhinoplasty was typically a reductive operation commonly

resulting in loss of support, while the focus is on restructuring the nose in modern

operations (Tardy and Toriumi, 2000).

Autogenous cartilage is the material most commonly used to restructure the

nose and provides material with which to strengthen, augment and reposition the

deviated dorsum. Sources of autogenous cartilages are the nasal septum, auricular

conchal cartilage and costal cartilage (Zoumalan et al. 2009).

It is clear that the crooked nose constitutes a problem but in actual practice

what may appear to be a brilliant success immediately after surgery can be proved

a failure few months later on the reappearance of the deviation to some degree.

This depends entirely on the cartilaginous structures of the nasal pyramid, which

retain the “memory” of the deviation due to their elasticity and tend to revert to

their original position over time like a spring (Boccieri and Camillo, 2013).

The difficulty in solving the problem of the crooked nose lies entirely in the

cartilaginous structure, especially the dorsal section of the nasal septum. While a

deviated nasal septum can in fact be largely removed, from a functional standpoint,

it is necessary in any case to leave an L-shaped structure capable of supporting the

nasal pyramid as a whole. But also this structure must be modified or the deformity

will remain (Tardy and Toriumi, 2000).

Numerous techniques described, involving the use of certain appraoches

incisions and grafts to modify the cartilaginous portion of the dorsal pillar of the

septum and to straighten the nose (Zoumalan et al. 2009).

2

Introduction

Extracorporeal septoplasty, spreader grafts and the crossbar graft are all

particularly effective, not only in correcting deformity of the nasal pyramid but

also in solving functional respiratory problems (Boccieri and Camillo, 2013).

Operating on the concave side of the L-strut and positioning spreader grafts

at one or both sides can be an effective mean for correction when a gentle

convexity of the dorsal strut is present (Gubisch, 2005).

However, when the dorsal L-strut cephalocaudal convexity is more severe,

spreader grafts may not be able to overcome inherent cartilage memory and are

likely to result in incomplete correction (Song et al. 2008).

Although extracorporeal septoplasty has been advocated as the ultimate

corrective procedure for complex nasal septal deformities, it may lead to

destabilization of the junction of the quadrangular cartilage and nasal bones (the

keystone area) (Gubisch, 2005).

Therefore, the use of “dorsal L-strut cutting and suture technique” for

correction of severe cephalocaudal convexity of the dorsal L-strut preserves the

keystone area and involves cutting the mid-section of the dorsal septum and then

reconnecting it using overlapping sutures (Song et al. 2008).

The present study examined the usefulness of the dorsal L-strut cutting and

suture technique for deviated nose with severe cartilaginous dorsal deflection.

3

The Aim of Work

The Aim Of Work

The Aim Of Work

The aim of this study is to assess the use of “dorsal L-strut cutting and suture

technique” with spreader graft insertion in correction of severe cases of

cartilaginous deviation of the nose and compare it with the use of spreader graft

alone as regard the aesthetic results as well as their hazards.

4

Reviewof Literature

Anatomy of The External Nose


Assessing the external nose requires an understanding of the anatomical

components that contribute to its normal topographical features (Oneal et al.

1993).

The tissues covering the nasal frame vary significantly in thickness. These

tissues are thick cephalically and caudally. Then become thinner in the center. The

soft tissue components of the nose include skin, muscles, nerves and the vascular

elements (Guyuron, 2006).

In general, the nose has more sebaceous glands than most other parts of the

face and body. These glands are more abundant in the caudal third of the nasal skin

Figure (1): Structural support of the nose (Ducic and Defatta, 2007).

5


than the middle and cephalic portions. The skin color, consistency and thickness

vary from patient to patient (Guyuron, 2006).

There are four distinctive layers that occupy the area between the skin and

the underlying osseocartilaginous frame: the superficial musculoaponeurotic

system (SMAS), fibromuscular layer, deep fatty layer in which the major

superficial blood vessels and motor nerves run and the fourth soft tissue layer is the

periosteum over the nasal bones and the perichondrium over the cartilaginous

frame (Saban et al. 2008).

Under the SMAS there is a thin fibrofatty layer that divides to encase the

superficial and deep muscles of the nose. Wherever there is no muscle, these two

layers join to create a single layer (Saban et al. 2008).

The third layer of the nose is the deep fatty layer that separates the

fibromuscular layer from the underlying nasal frame. The major superficial blood

vessels and motor nerves run within it. A distinctive feature of this layer is that it

does not have fibrous septa and its role is to facilitate movement of the

fibromuscular layer over the frame (Saban et al. 2008).

The fourth soft tissue layer is the periosteum over the nasal bones and the

perichondrium over the cartilaginous frame (Saban et al. 2008).

The muscles of the nose are thin and difficult to visualize. So it is a

challenge to consistently preserve them (Hwang, 2006).

The most cephalic muscle of the nose is the procerus, which moves the

eyebrows caudally. The nasalis muscle serves as blanket for the nose. Removal of

this muscle leads to skin dimpling and exposure of any imperfections in the frame.

(Hwang, 2006)

6


Figure (2): An illustration of the nasal musculature (Guyuron et al. 2012).

Depressor alae muscle originates from the border of the pyriform crest and

then rises vertically up to the ala, acting as a depressor and constrictor of the

nostrils. Levator labii superior muscle has fibers that are attached to the nostril,

thus contributing to its dilatation. Paralysis of these muscles will cause collapse of

the external valve (Hwang, 2006).

The depressor septi nasi muscle depresses the nasal tip and alters the air

turbulence. Its contraction causes narrowing of the labiocolumellar angle (Hwang,

2006).

Both the external and internal carotid arteries provide blood supply to the

external nose.

The angular artery branch of the facial artery provides most of the arterial

circulation to the lateral nose. The dorsal nasal artery communicates with the

infratrochlear artery (Nakajima et al. 2002).

7


Figure (3): Illustration of blood supply to the nose (Guyuron et al. 2012).

Figure (4): Illustration of the sensory innervation of the nose (Guyuron et al. 2012).

The lateral branches of the infraorbital artery also provide arterial

circulation to the nose. Additionally, the nose receives circulation from the

superior labial artery from the facial artery (Nakajima et al. 2002).

The maxillary and ophthalmic branches of the fifth cranial nerve provide

sensory innervation to the nose. The supraorbital and supratrochlear branches of

the ophthalmic nerve supply the sensory innervation to the cephalic portion of the

nose (Han et al. 2004b).

The external nasal branch of the anterior ethmoid nerve provides innervation

to the mid-vault area and extends to the tip of the nose. The infraorbital nerve

provides sensory innervation to the nose posteriorly (Han et al. 2004b).

External Nasal Frame

The nasal frame has two distinctive components. The cephalic portion of the

nose consists of bony vault and the caudal portion is cartilaginous (Guyuron et al.

2012).

8


The Bony Vault

The bony vault is composed of a pair of nasal bones and the ascending

frontal process of the maxilla (Toriumi, 1995).

This part of the nose is pyramidal in shape with the narrowest portion being

at the intercanthal line. The nasal bones become thicker cephalically, so any

osteotomy above the intercanthal line may become somewhat arduous (Toriumi,

1995).

There are variations in the length of the nasal bones related to race. This is

significant, as any abnormalities in the width of the nasal bones can distort the

aesthetic dorsal lines. The nasal bones join with the frontal process of the maxilla

laterally (Toriumi, 1995).

However, incorporation of a portion of this frontal process with the nasal

bone osteotomy will ensure a better nasal definition and avoid a step deformity.

The circle created between the nasal spine, the thin portion of the frontal process of

Figure (5): Illustration of the external nasal frame (Guyuron et al. 2012).

9


Figure (7): View of the bony and cartilaginous nasal frame (Guyuron et al. 2012).

Figure (6): confluence of cartilaginous nasal septum, ethmoid bone, and nasal bone is called “the keystone area” (Guyuron et al. 2012).

the maxilla and the thin caudal border of the nasal bones is called the pyriform

aperture (Meyer, 2002).

The confluence of cartilaginous nasal septum, ethmoid bone and nasal bones

is called the keystone area. When the dorsum is lowered significantly, the keystone

area is weakened and the roof of the nose is opened (Guyuron et al. 2012).

The Cartilaginous Nasal Frame

The cartilaginous caudal portion is formed of upper and lower lateral

cartilages.

Upper Lateral Cartilages The upper lateral cartilages are a pair of rectangular cartilages that support

the lateral nasal walls. These cartilages join the septum in the midline. The angle

between the caudal border of the upper lateral cartilage and the septum, which is

usually 10–15 °, constitutes the internal valve along with the border of the inferior

10


turbinates. The cephalic portion of the upper lateral cartilages is overlapped by the

nasal bones (Han et al. 2004a).

Lower Lateral Cartilages

The lower lateral cartilages have four components: medial crus, middle crus,

lateral crus and dome.

The Medial Crus is formed of footplate and columella. The footplate varies

in size and angulation. The columella varies in length and width. The Middle Crus

extends between the medial crus and the dome.

The Lateral Crus is the largest component. The anterior portion of this

cartilage can curve in a variety of directions. It controls the convexity of the ala

and contribute to the function of the external valve. Generally, this cartilage is

oriented at a 45° angle to the vertical facial plane.

The Dome is the narrowest, thinnest and most variable portion of the lower

lateral cartilage. The area between the medial and lateral segments contains soft

tissue covered externally with skin and internally with the vestibular lining and is

called the soft triangle (Han et al. 2004a).

Figure (8): View of the cartilaginous nasal frame (Guyuron et al. 2012). 11


Nasal Septum

The nasal septum is bony cephalically. On the other hand it is cartilaginous

and membranous caudally. The bony portion includes the perpendicular plate of

the ethmoid bone, the vomer and the maxillary crest (nasal crest of maxilla).

(Meredith, 2001)

The perpendicular plate of the ethmoid bone forms the upper third of the

bony septum and is continuous with the frontal bone and the cribriform plate.

(Meredith, 2001)

Anteriorly, this bone joins the nasal bones in the midline. Caudally, it is in

contact with the cartilaginous septum and inferoposteriorly it is in continuity with

the vomer bone (Meredith, 2001).

The vomer bone is like the keel of a boat and extends from the sphenoid

bone superiorly to the nasal crest of the palatine bones and maxilla inferiorly.

(Behrbohm and Tardy, 2004)

The most projected caudal portion of the premaxilla is the anterior nasal

spine that forms a bony groove providing support to the septal cartilage. It is deep

Figure (9): Nasal septum (Meredith, 2001).

12


anteriorly and gradually becomes flatter as it extends posteriorly (Behrbohm and

Tardy, 2004).

The septal cartilage, which is also called the quadrilateral cartilage, is flat

and varies in size and shape. The cartilage connects with the perpendicular plate of

the ethmoid posteriorly and fuses with the vomer bone and premaxillary wings.

The junction between the dorsal and caudal portion of this cartilage is called the

anterior septal angle (Behrbohm and Tardy, 2004).

13

Physiology of The Nose


Nasal physiology is complex, dynamic and essential to the quality of life.

The nose forms a passage and mechanism for warming of the oxygenated air that

flows into the lungs. Also it acts as a humidifier and an olfactory system (Guyuron

et al. 2012).

Nasal breathing is the sole physiologic mechanism of ventilation,

disturbance of which can lead to mouth breathing and consequential dryness of the

lower respiratory tract, which can result in disease conditions such as pharyngitis,

asthma, bronchial hypertrophy, bronchitis and laryngitis (Guyuron et al. 2012).

Nasal obstruction can be caused by structural abnormalities as septal

deviation, hypertrophied turbinates, nasal valve incompetence or intranasal masses,

all of which consequently increase nasal resistance and thus decrease nasal airflow.

The internal nasal valve is considered the most common site of nasal airway

obstruction (Han et al. 2004).

The nose is capable of providing warmed air into the lungs with a constant

temperature of 31-34°C. Additionally, the nose provides 90-95% humidification to

the inspired air. Both humidification and temperature regulation undergo swift

changes in different parts of the nose. (Rouadi et al. 1999).

In the lumen of the nose the air becomes slow and forms two streams. The

main stream is directed to the floor of the nose (Meredith, 2001).

The smaller stream is directed upwards and sweeps over the dorsum of the

inferior nasal turbinate. At this point, the air is warmed and continues to move

upward. Upon reaching the head of the middle turbinate, the upward draft splits

14


into a lateral stream that ventilates the paranasal sinuses and a medial stream that is

directed upward. The alignment of the middle turbinate is crucial for ventilation of

the olfactory groove. Additionally, the nose functions as a filter and perhaps the

front line of defense working with the immune system (Meredith, 2001).

The mucus produced by the epithelial cells in the conducting layers forms a

layer called the mucociliary blanket. This blanket produces a positive electrostatic

charge on the nasal cavity walls (Broker and Berman, 1997).

Negatively charged foreign particles that are inspired will be attracted to the

nasal walls and are thus prevented from traveling further distally to more sensitive

areas of the respiratory tract. Larger particles will be trapped within the vibrissae

found just within the nasal vestibule (Broker and Berman, 1997).

The cilia, which are constantly in motion, move the mucociliary blanket with

its entrapped particles towards the oropharynx, where it is subsequently swallowed

or expectorated (Broker and Berman, 1997).

The optimal turbulence of the nose will occur with a nasolabial angle of 90-

115°. An obtuse angle will lead the air directly to the nasopharynx, while a

narrower angle will result in airflow into the cephalic nose (McCaffrey and

Remington, 1998).

Any abnormal airflow can result in stagnation of secretions in certain parts

of the nose, which ultimately may result in foci of infection, localized bleeding and

foul odor (McCaffrey and Remington, 1998).

The area of respiratory epithelium located in the hemiolfactory groove

measures approximately 2 × 5 cm. There are approximately 10 million olfactory

cells in the human nose. These are bipolar sensory cells with an elongated cell

15


body and short process with numerous cilia that extend into the nasal mucous spine

(Guyuron et al. 2012).

The axons are at the opposite end of the cells and pass through the basal

membrane of the olfactory epithelium and join to form fila olfactoria. These

filaments pass through the cribriform plate to enter the olfactory bulb in the brain.

The information is relayed through the olfactory tract to the olfactory cortex,

thalamus, hypothalamus and amygdale (Younger, 1997).

In certain conditions as septal deviation, polyps, tumors and deformities of

the nasal turbinates (lateralization, atrophy, paradoxical curvature) respiratory

hyposmia can result from deficient aeration of the olfactory groove (Han et al.

2004).

One of the secondary functions of the nose is the role it plays in voice

quality. The quality of our voice depends on the resonance of air through the

mouth, pharynx and nose. One of the commonly asked questions by patients is

whether nasal surgery will alter the sound of their voice. However postsurgical

changes in voice quality have not been substantiated (Broker and Berman, 1997).

16

Pathogenesis of Nasal Deviation


The septum constitutes the main central support for the nose. The

perpendicular plate of the ethmoid is in continuity with the posterior edge of the

quadrangular cartilage and both structures are aligned caudally with the vomer.

The most anterocaudal portion of the septal cartilage rests on the maxillary crest in

a tongue-and-groove relationship. This relationship between the cartilage and the

bone renders this portion of the septum susceptible to post-traumatic displacement

of the cartilage from the groove of the crest (Mendelsohn, 2005).

Nasal bones are the most commonly fractured bones in the face, and

fractured nasal bones are a leading cause of an asymmetric nose (Kim and

Toriumi, 2004).

The septum and the nasal bones control the direction of the nose. Thus,

deviation of the nose can result from misalignment of either one of them or a

combination of both (Most, 2006).




unit. A longstanding shift of the midline structures cannot be simply corrected with

osteotomies alone. It requires separation and realignment of all the structures

individually including the nasal bones, the septum and the upper lateral cartilages.

(Gubisch, 2005)

The term “crooked nose” is commonly used for all of the clinical conditions

involving deviation of the nasal pyramid from the midline (Most, 2006).

17


There are six classes of septal deviation. The most common type is a septal

tilt, in which the septum itself has no significant underlying curvature but is tilted

to one side because the caudal septum is dislodged to one side of the vomer bone

(Guyuron et al. 2012).

In cases of deviation, it can appear C-shaped or S-shaped or wholly

displaced to one side. This pathology is frequently found in clinical practice today

as the result of blunt trauma from sports or car accidents (Guyuron et al. 2012).

Figure (10): An illustration of classes of septal deviation:

(A) Septal tilt. (B) C-shape anteroposterior septal deviation. (C) C- shape cephalocaudal septal deviation. (D) S-shape anteroposterior septal deviation. (E) S-shape cephalocaudal septal deviation. (F) Llocalized deviation and septal spur.

(Guyuron et al. 2012)

18


Still more important than the social aspect of the crooked nose is its

psychological impact on the person. The face plays a crucial role in social

relations. According to this, the position of the nose in the middle of the face

means that any deviation will attract attention. It is therefore people with this type

of deformity usually have complexes and feel insecure (Boccieri and Camillo,

2013).

Injury leading to a crooked nose may be secondary to a recent event or to

years of scarrings and contractions following previous recurrent trauma (Boccieri

and Camillo, 2013).

Nasal fractures commonly result from lateral forces. In this type of injury,

the nose may appear deviated but it is not. This illusion is caused by depression of

a unilateral bony fragment. For example, unilateral trauma may fracture one nasal

sidewall, creating the illusion of nasal dorsum deflection to the opposite side. This

type of injury carries a good prognosis for the restoration of function (Pontius and

Leach, 2004).

A truly deviated nasal fracture occurs with greater frontal force and less

lateral force. Greater force is needed from frontal impact to produce nasal fracture,

as nasal bones are buttressed by frontal process of the maxilla, nasal spine and

perpendicular plate of the ethmoid. Direct frontal injury causes fracture and splays

the nasal bones (Pontius and Leach, 2004).

The septum which is the shock absorber of the nose could be fractured and

displaced from its position. Nasal trauma associated with septal fracture requires a

more extensive repair process (Gurlek et al. 2006).

19


Neglected or partially reduced nasal fractures usually result in a crooked

nose associated with surface depressions and irregularities. These patients often

present without prior medical attention and many noticed progressive nasal

changes following a traumatic event (Kim and Toriumi, 2004).

Patients with external nasal deformity frequently experience progressive

nasal obstruction. Offending trauma leads to both septal deviation and disruption

of traditional nasal support mechanisms. With loss of nasal support, internal and

external nasal valve collapse could result (Dayan et al. 2009).

Children are frequent recipients of trauma leading to progressive deviation.

A child’s nose is composed primarily of cartilage. The nasal bones are smaller,

softer, more compliant and capable of absorbing energy from the force of trauma

(Dayan et al. 2009).

Birth trauma may result in nasal septal deviation. Nasal septal deformities

are estimated to occur in up to 23% of newborns. Forceps assisted or breech

delivery is often mentioned as the etiology of injury. However intrauterine forces

may also be responsible for neonatal cartilage deformities (Dayan et al. 2009).

Diseases of the septum and internal nose may cause resorption of supporting

structures leading to collapse of nasal valves and deviation.

(Littlejohn et al. 1998)

Physicians could miss this category of diseases while making a differential

diagnosis of the etiology of presenting case with asymmetric nose. Connective

tissue diseases play an important role in etiology of non traumatic nasal deviation.

Unless a correct diagnosis is made, many symptoms and anatomic abnormalities

20


will recur or progress despite attempts at surgical correction (Littlejohn et al.

1998).

Other diagnostic considerations include drug abuse and neoplastic processes.

Nasal inhalation of cocaine leads to ulceration of nasal mucosa. With consistent

use, mucosal atrophy and septal perforation may occur (Littlejohn et al. 1998).

In cases of neoplastic or polypoid disease, careful inspection of the nose

reveals mucosal changes. Nasal bones and cartilage may become lateralized,

creating asymmetries in the middle and upper third regions of the nose. The

surgeons need to assess patients properly for detection of these less obvious causes

of a deviated nose (Littlejohn et al. 1998).

Many patients who seek either cosmetic or functional benefits of rhinoplasty

are initially pleased with their new appearance. Years later, as the forces of healing

begin to manifest, patients may become disappointed (Shah and Constantinides,

2006).

Rhinoplasty is a complex surgical procedure associated with potential

complications. Unfortunately, reduction rhinoplasty frequently results in loss of

structural support of the nose. Gravity and aging pulls the nose in different

directions and can result in nasal collapse and deviation. Asymmetric or

incomplete osteotomies result in deviation of the upper third region of the nose and

obvious step deformities (Guyuron et al. 2012).

Despite complete and symmetric osteotomies, if the nasal structures

responsible for the deviation are not corrected, the nasal pyramid may migrate back

to its original position (Shah and Constantinides, 2006).

21

Preoperative Assessment

Figure (11): An illustration of Surface markings of the face (Prendergast, 2012).


For a successful rhinoplasty outcome, there should be a perfect harmony

between the nose and the rest of the face. Understanding this harmony is helpful in

plans made for rhinoplasty. Furthermore a full understanding of the patient’s

concerns is required to make sure that the imperfections seen by the patient

matches the surgeon’s hopes from the surgery (Larrabee et al. 2004).

The area anterior to the auricles, from the hairline superiorly to the chin

inferiorly, represents the human face. The forehead occupies the upper face, from

the hairline to the eyebrows. There is a subtle prominence between the eyebrows

called The Glabella (Prendergast, 2012).

22


Figure (12): Soft-tissue cephalometric points. (G) The glabella. (N) The nasion at the root of the nose (R) The rhinion is the junction of the bony and cartilaginous dorsum of the nose in the midline. (T) The tip. (S) The subnasale is the junction of the columella and upper cutaneous lip. (SL) The superior labrum is the junction of the red and cutaneous parts of the lip at the vermilion border. (St) The stomion is the point where the lips meet in the midline. (IL) The inferior labrum is the point in the midline of the lower. (Sm) The supramentale is midpoint of the labiomental crease between the lower lip and chin. (P) The pogonion is the most anterior point of the chin. (M) The menton is the most inferior point of the chin. (C) The cervical point is the point in the midline where the neck meets the submental area. (Tr) The tragion is the most superior point on the tragus (Prendergast, 2012).

In the midline, several soft-tissue cephalometric points are defined along the

midsagittal plane from the glabella superiorly to the cervical point inferiorly.

(Prendergast, 2012)

Centrally, the columella connects the apex of the nose to the philtrum of the

cutaneous upper lip. The junction of the red part of the lips with the skin is the

vermillion border. In the midline, the top lip projects anteriorly as the tubercle.

Below the lower lip, the labiomental groove passes between the lip and the chin.

Between the alae of the nose and the lateral borders of the lip, the nasolabial

groove or fold separates the upper lip from the cheek. The soft tissue of the upper

lateral cheek projects anteriorly over the zygomatic arch and represents a feature of

beauty in most cultures (Prendergast, 2012).

23


Figure (13): Horizontal facial thirds. The upper third extends from the

hairline to glabella, the middle third from glabella to subnasale, and lower third from subnasale to menton. The lower third is further divided into third from subnasale to stomion, and two thirds from stomion to menton. On the frontal view, the nasal tip region should have four visible landmarks: supratip break, columellar-lobular angle and two tip defining points. Connecting these points results in a symmetric baseball diamond configuration centered in the midline of the nasal tip (Ducic and Defatta, 2007).

Figure (14): Vertical fifths. The eye usually measures one-fifth the width of the face (Prendergast, 2012).

The face is divided into horizontal thirds (Ducic and Defatta, 2007).

The face can be vertically divided into fifths, with the width of each eye, the

intercanthal distance and the nasal width all measuring one-fifth. However, studies

using photogrammetric analyses in white and asian subjects found variations in

these proportions (Sim et al. 2000).

24


Figure (15): Nasal proportions (Prendergast, 2012).

Figure (16): The Baum ratio used to calculate nasal tip projection. The length of the nose (a) divided by a perpendicular line (b) from the nasal tip to the line from the nasion to subnasale gives the ratio (Prendergast, 2012).

Crumley and Lancer described appropriate projection of the nose and nasal

tip. A ratio of 5:4:3 between a line from the nasion to the nasal tip, a line from the

nasion to the alar crease and a perpendicular line that joins the other two

respectively (Crumley and Lanser, 1988).

Nasal tip projection can be measured using other parameters. The Baum

ratio is calculated by dividing the length of a line from the nasion to the nasal tip

by the length of a perpendicular line from the nasal tip to a vertical line from the

subnasale (Leach, 2002).

25


Figure (17): The Simons ratio used to calculate nasal tip projection. A line from the subnasale along the anterior aspect of the columella to the nasal tip (a) divided by a line from the subnasale to the superior labium (b) gives the Simons ratio (Prendergast, 2012).

The Simons ratio also reflects nasal tip projection through dividing the

length from the subnasale to the nasal tip by the length from the subnasale to the

superior labium (Leach, 2002).

In general on profile view, the deepest portion of the nasofrontal angle

should be at the upper lash line and supratarsal fold. Assuming normal upper lip

projection, a vertical line drawn through the most projecting portion of the upper

lip will help define the adequacy of nasal tip projection. Adequate projection will

be associated with 50 to 60% of the nasal tip lying anterior to this line (Ducic and

Defatta, 2007).

Nasal length may be correlated to nasal tip projection with a normal ration

approximating 1:0.67. In females, the nasal dorsum should lie approximately 2 mm

posterior and parallel to a line drawn from the nasofrontal angle to the most

anterior point of tip projection. Males should generally approximate this line. The

nasolabial angle is defined as the angle between a line drawn through the most

anterior and posterior points of the nostrils (on lateral view) and a perpendicular

line dropped from the natural horizontal facial plane (Ducic and Defatta, 2007).

26


Figure (18): Preoperative analysis lateral view (NLA) naso-labial angle. (NFA) naso-frontal angle. (CLA) columella-lobular angle.

(Ducic and Defatta, 2007)

Rotation is determined by the degree of the nasolabial angle. It should

generally be between 90 to 100°, with the higher end preferred for most females

and the lower end of the spectrum preferred for most males. Patient height and

surrounding facial features will determine ideals in this regard (Ducic and Defatta,

2007).

27


Figure (19): Basal view of the nose. (A) Normal tip: the lobule should represent approximately one-third (upper third) and the

columella two-thirds (lower two-thirds) of the basal view. The width of the lobule (nasal tip) should be about 35–45% the width of the nasal base (Prendergast, 2012).

(B) Boxy tip. (C) Bulbous tip.

(Ducic and Defatta, 2007)

The basal view of the nose can be divided into thirds with the ratio of the

columella to the lobule about 2:1 (Abdelkader et al. 2005).

Prior to functional and aesthetic nasal analysis, a complete head and neck

examination including flexible nasolaryngoscopy should be performed to detect

any concomitant pathology that should be treated first. Nasal examination focuses

on inspection, palpation and assessment of function (Moody and Ross, 2006).

The surface anatomy of the nose is directly related to the underlying

structures, so the examination in the outpatient setting will be of considerable help

in planning the procedure (Rohrich and Muzaffar, 2006).

28


The skin changes associated with age will have an effect on rhinoplasty

outcome. Thin skin over the dorsum will not hide minor bony irregularities. Also

rhinophyma affecting the tip may have both functional and cosmetic consequences.

Palpation will help to confirm the thickness of the skin, the elasticity, shape of the

cartilages and extent of tip support (Rohrich and Muzaffar, 2006).

Psychological elements are common factors causing rhinoplasty failure and

may result in disappointment in spite apparently successful procedure.

Recognizing a patient who may not be pleased with the outcome of surgery or who

has unrealistic expectations is extremely difficult and is an acquired skill slowly

attained with experience (Ritvo et al. 2006).

Detection of certain signs can provide sufficient information for the surgeon

to suspect an underlying psychological condition that will lead to patient

dissatisfaction regardless of the surgical outcome (Ritvo et al. 2006).

Table (1): Signs suspecting psychological problems (Ritvo et al. 2006).

29


A detailed patient history of nasal trauma, previous nasal surgery, airway

complaints and allergies is obtained. Observation of the external nose and face

should include attention to oral or nasal breathing. Mouth-breathing can be

continuous or intermittent. A persistent unilateral obstruction of the airway is a

more reliable indicator of mechanical airway compromise (Moody and Ross,

2006).

On the other hand, a negative history of airway obstruction is not a reliable

indication of a patent airway. However, obstruction that occurs only during deep

inspiration may indicate an incompetent internal or external nasal valve (Moody

and Ross, 2006).

Examination of the oral cavity may reveal a very high and narrow palatal

arch that encroaches on the nasal airway. Such patients commonly have a very

constricted nasal cavity (Moody and Ross, 2006).

The nose is then observed zone by zone for deviated structures including the

nasal bones, the anterior septum and lateral cartilages (Mckiernan et al. 2001).

A basilar view with the head tilted back may disclose columella, tip,

footplate, nostril and alar base asymmetry. An overhead view is helpful for

detection of external nasal deviation (Mckiernan et al. 2001).

Examination should include palpation of the nasal bones, upper lateral

cartilages, lower lateral cartilages, the membranous septum, the caudal

cartilaginous septum and the anterior nasal spine (Mckiernan et al. 2001).

The internal nose is examined for detection of septal deviation, enlarged

turbinates, synechiae, perforation, spurs and contact between the turbinates and the

septum (Litner et al. 2008).

30


Any crusting, purulence, ulceration or presence of polyps should be noted.

The color and size of the turbinates are also noticed. A pale turbinate mucosa may

indicate allergy, whereas an erythematous mucosa may indicate an infection or

inflammatory process indicating rhinitis (Litner et al. 2008).

Posterior rhinoscopy is often helpful in symptomatic patients. Visualization

of the posterior nasal airway is best achieved using a 0° nasal endoscope (Litner

et al. 2008).

Investigations as computed tomography to detect any pathology that may

affect the nasal cavity and sinuses could be helpful (Litner et al. 2008).

Photography

Standardized, high quality preoperative photographs of the nose are critical

for preoperative rhinoplasty planning, comparative postoperative assessment and

demonstration of surgical results (Staffel, 1997).

The three standard views that give 95% of the visual information necessary

for the surgeon to evaluate nasal anatomy and visualize the underlying nasal

structures are frontal, profile (left and right) and basal (Staffel, 1997).

There are also oblique views for documentation, but usually only the first

three are used for preoperative planning and intraoperative analysis (Staffel, 1997).

Some surgeons also recommend a cephalic view to obtain a better view of

the nasal dorsum. It is often helpful to obtain a smiling lateral view to determine

whether the dynamics of the tip change with smiling (Staffel, 1997).

31


Figure (20):Photography views with proper lightening. (A) Frontal view. (B) Lateral view. (C) Basal view. (D) Oblique view. (E) Cephalic view. (F) Right

profile no smiling. (G) Right profile smiling. The use of proper flash technique to eliminate shadows. The harsh lighting in these pictures illustrates the external nasal anatomy clearly and delineates tip subtleties (Galdino et al. 2001).

The lighting arrangement is perhaps the most critical factor in producing

high-quality rhinoplasty photographs. Using different lighting arrangements, light

sources or even light positions can have a dramatic effect on the photographic

results (Dibernardo et al. 1998).

There are several different lighting arrangements that one could use in a

practice for photodocumentation to demonstrate clearly the external anatomy of the

nose and any surface defects present especially the contours of the tip, the shape

32


and symmetry of the dorsum and the appearance of the alar cartilages (Dibernardo

et al. 1998).

The lighting must provide highcontrast detail to the anatomy, the appearance

of texture and sharp lines of demarcation of the nose to allow the surgeon to

mentally visualize the underlying nasal anatomy (Dibernardo et al. 1998).

High-quality lenses are recommended for patient photodocumentation,

especially for rhinoplasty photography. These lenses aim to prevent distortion and

provide a high depth of field, so that the entire face is in focus (Galdino et al.

2001).

Lenses recommended for facial medical photography fall in the range of 90

to 105 mm in focal length. These lenses are known as portrait lenses that

photograph the facial anatomy without introducing a distortion that is often seen

with shorter focal lenses 60 mm (Galdino et al. 2001).

Shortfocal-length lenses often produce a distortion (central bulging) of the

face and should be avoided for medical portrait photography (Galdino et al. 2001).

Figure (21): The effect of lens distortion, known as central bulging, using a 50-mm (A) versus a 100-mm (B) lens (Galdino et al. 2001).

33


It is imperative that strict attention is given to the patient’s head position

when photographing standard views. Position of the head (head tilt up, down or

slight rotation) can dramatically affect the appearance of the nose and nasal

anatomy. The patient should be relaxed expressionless, especially no smile, unless

directed to do so. Smiling can pull the nasal tip downward creating an illusion of

dorsal convexity. Furthermore taking photographs without makeup or jewelry, both

preoperatively and postoperatively is recommended (Dibernardo et al. 1998).

Care must be taken to ensure that the patient is looking straight ahead with

the head positioned in the natural horizontal facial plane. The natural horizontal

facial plane is the plane when the patient is relaxed looking straight ahead, as if

looking into a mirror at eye level (Dibernardo et al. 1998).

Figure (22): The importance of head position.

(A) &(C) The nose is aligned straight despite that the head is slightly rotated to the left.

(B) &(D) There is a slight deviation of the nose to the right while the patient is looking straight ahead.

The panel on right is preferable to the panel on left when assessing the nose, because the head is straight, showing the deviation (Galdino et al. 2001).

34


However, in patients with low-set ears (low external auditory canals) the

chin always appears weak (when in fact it is normal) and the angle of rotation of

the nose (nasolabial angle) will appear decreased. It is recommended to have a

height-adjustable swivel chair and to have the patient look at a fixed object in the

room located at eye level (Dibernardo et al. 1998).

High-quality, standardized photographic documentation in rhinoplasty is

essential for preoperative planning, demonstration of surgical results and patient

education.

Obtaining the best photographic results requires attention to specific lighting

that eliminats shadows while highlighting the external nasal anatomy with sharp

demarcating lines, texture and contrasting detail. Furthermore, consistency with

patient positioning in standard views and accurate color reproduction is necessary

to achieve adequate assessment in preoperative photography (Staffel, 1997).

In addition, a reliable and professional single-lens reflex camera system,

whether 35-mm or digital, along with high-quality portrait lenses is essential to

produce the best results (Galdino et al. 2001).

Finally, the output method should produce nicely contrasting and high

photographic quality images (Staffel, 1997).

35

Surgical Approaches in Rhinoplasty


Form and function are closely linked in rhinoplasty. Thus, a symmetric,

natural appearing nose with fundamentally sound structural support will generally

serve the patient well in terms of breathing. Rhinoplasty remains one of the

challenging surgical procedures facing the facial plastic surgeons (Karaaltin et al.

2009).

Open rhinoplasty has become the common technique used to perform

rhinoplasty over the past two decades. This has occurred because the open

approach does not have the same limitations as the endonasal approach.

Limitations such as poor diagnostic capability from the inability to identify small

anatomic differences not observable from the surface, hidden anatomy, limited

binocular vision, suturing and fixation techniques that may be difficult to

impossible to perform endonasally and restricted access to individual skeletal

structures. However, the endonasal approach to rhinoplasty is very useful in certain

circumstances (Karaaltin et al. 2009).

Closed rhinoplasty (Endonasal Approach)

With closed rhinoplasty techniques, there is generally less disruption of soft

tissue support than open techniques. Although visualization is inferior compared

with open techniques, one can achieve tremendous beneficial changes in

appearance with improvement of the airway by applying and maintaining a strict

adherence to certain principles (Ducic and Defatta, 2007).

Septoplasty is performed to address any nasal airway obstruction arising

from septal deviation as well as to harvest cartilage grafts that may be needed for

36


later augmentation while maintaining dorsal and caudal struts of approximately 1

cm to preserve septal support (Nease and Deal, 2012).

If the caudal septum is trimmed for caudal deflection or to alter the

nasolabial angle, it is important to preserve as much membranous septum as

possible to maintain normal mobility of the lower one third of the nose following

rhinoplasty (Nolst-Trenité, 2009).

The basic technique for standard closed rhinoplasty remains the

transcartilagenous approach (Ducic and Defatta, 2007).

Transcartilaginous Approach

The transcartilaginous entry into the nasal anatomy uses only one incision

within the structure of the lower lateral cartilage itself. The transcartilaginous

incision is also named the intracartilaginous or cartilage-splitting incision, because

it occurs within the lower lateral cartilage, actually dividing or “splitting” the

cartilage. This single incision, when extended into the chosen septal incision, will

allow excellent exposure of the entire lower two thirds of the nose (Tardy, 2004).

The ala is retracted with a sharp wide double hook and one incision is made

through the vestibular skin. The incision is placed several millimeters above the

caudal end of the lower lateral cartilage and extends from the dome area laterally

to the midsegment of the lower lateral cartilage with care taken to maintain

adequate structure laterally to avoid pinched alar collapse and nasal obstruction.

(Guida, 1999)

Medially, from the septal angle, the incision is continued into the desired

septal incision. This approach is repeated on the opposite side, with extreme care to

maintain perfect symmetry (Guida, 1999).

37


The blade is inserted through the transcartilaginous incisions on both sides to

elevate the skin and soft tissue envelope just above the perichondrium of the upper

lateral cartilages and septum. This maneuver is performed to the level of the

periosteum of the nasal bones to provide excellent exposure of the lower two thirds

of the nose (Guida, 1999).

Caudal Septal Incision (Hemitransfixion) an incision used in endonasal

approach

The caudal septal incision, also known as the hemitransfixion incision, is

made about 2 mm above and parallel to the caudal margin of the cartilaginous

septum. It provides access to the septum, anterior nasal spine, nasal dorsum,

columella and floor of the nasal cavity. A right-handed surgeon makes the caudal

septal incision on the right side, even if the caudal septal end is dislocated to the

left. The incision should follow the full length of the caudal margin of the septal

cartilage. Care is taken to not cut into the nostril (Becker, 2003).

Figure (23): Transcartilaginous Approach (Guida, 1999).

38


Addressing the nasal septum:

The caudal septal end is subperichondrially dissected over its full length,

from its ventrocaudal corner to the anterior nasal spine, by means of a sharp knife

with sharp and slightly curved scissors. The caudal septal end must be fully

exposed to gain full access to the nasal dorsum, anterior nasal spine, premaxilla,

nasal floor and columella (Konstantinidis et al. 2005).

Complete dissection of the caudal end is also essential for correcting a

deviated caudal septal end, septal reconstruction, shortening of the nose and

rotation of the tip. The mucoperichondrium is elevated in a cranial direction and in

a caudal direction to expose the caudal end of the cartilage. The pointed, slightly

curved scissors are introduced to completely free the caudal border of the cartilage

and expose its ventrocaudal corner (Konstantinidis et al. 2005).

The next step is to expose and mobilize the cartilaginous and bony septum.

This phase consists of elevating the mucoperichondrium and creating a bilateral

Figure (24): Caudal Septal Incision. (A) The caudal septal incision is the universal approach to the septum,

dorsum, columella and nasal floor. (B) The caudal end of the septum is exposed by scraping aside the last

perichondrial fibers with a Cottle knife or a pointed, slightly curved scissors.

(Guida, 1999)

39


anterosuperior tunnel in combination with a unilateral or bilateral inferior tunnels,

if required (Konstantinidis et al. 2005).

Transfixion Incision

The transfixion is an incision through the membranous septum just in front

of the caudal end of the cartilaginous septum. It is usually made continuous with

bilateral intercartilaginous incisions to provide wide access to the septum and the

whole pyramid. Because of some complications as retraction of the membranous

septum or columella and drooping of the tip, it was replaced by the caudal septal

incision as the method of choice to approach the septum (Sedwick et al. 2005).

Figure (27): The transfixion incision (Guida, 1999).

Figure (26): Two-tunnel approach (Guida, 1999).

Figure (25): The anterior nasal spine and the chondrospinal junction are exposed (Guida, 1999).

40


Retrograde Approach

This approach is similar to the transcartilaginous approach. Exposure is

obtained using a sharp wide double hook and bilateral intracartilaginous incisions

are used. The intercartilaginous incisions are placed between the caudal end of the

upper lateral cartilage and the cephalic margin of the lower lateral cartilage and

then carried into the appropriate septal incision (Guida, 1999).

The intercartilaginous incision courses along the obvious edge of the caudal

end of the upper lateral cartilage as it articulates with the cephalic edge of the

lower lateral cartilage. This edge is brought into full view by retracting the ala with

the skin hook while simultaneously providing gentle pressure with the middle

finger over the upper lateral cartilage. The vestibular skin is undermined in a

retrograde fashion. The undersurface of the lower lateral cartilage is then exposed

and approached according to the plan of the surgery (Guida, 1999).

Figure (28): Delivery of the lower lateral cartilage using endonasal approach with intercartilaginous and marginal incisions (Guida, 1999).

41


Open techniques

In close techniques, incisions are inside the nasal cavity and are not visible

whereas in the open ones the first incision is on skin of columella. Recovery period

is shorter in close techniques with no visible scars. Their downsides are poor

visibility of the surgical field and inability to correct nasal pyramid deformities. In

open techniques, the recovery period is longer and scars on columella are visible.

Their advantage is the possibility of complete reconstruction of the nasal pyramid.

Also with open techniques it is possible to insert grafts with precision and fixing

them perfectly to cartilage tissue and soft structures of nasal pyramids (Kljajic and

Savovic, 2011).

All incisions in open techniques can be divided into columella incisions and

incisions of nose vestibule. Columella incision is the key element in performing

open surgeries. This incision considered a disadvantage of this technique. When a

cut is done in the columella region degree of scar formation depends on individual

characteristics and some populations can be more prone to visible scar occurrence.

So due to this reason, it is necessary to ask a patient if they have any body scars

after another surgery or an injury to assess the size of the scar to avoid the risk of a

hypertrophic columellar scar occurrence (Adamson and Litner, 2009).

Columella incisions can be divided into: “V” incisions, Modified “W”

incisions or Stair-shaped incisions. According to the region where columella

incision is done, they are divided into high (upper third), medium (in the mean

third of columella) and low (in the lower third). Besides incisions, it is necessary to

do both sided precartilaginous incisions. These incisions enable lifting off nasal

soft tissue completely (Adamson and Litner, 2009).

42


When both-sided precartilaginous incision is done. Using fine scissors with

sharp ends, the skin over the alar cartilage is lifted. Along the anterior edge of

medial branches of alar cartilages, soft tissues are lifted together with skin. When

the whole columella is lifted to the passage of lateral to medial crus, both alar

cartilages, soft tissue lifting is continued along perichondrium itself. The surgeon

has to be particularly cautious at this point. If a larger skin part is removed from

subcutaneous tissue, there is a danger of necrosis in the postsurgical period. Soft

tissue lifting continues directly above the pericondrium until the keystone region

then more till the periosteum (Huizing and Degroot, 2003).

When the nasal pyramid skeleton exposure is achieved, the surgeon

approaches the nasal septum from above. The caudal septum can be exposed

bilaterally down to the maxillary spine and crest if needed (Huizing and Degroot,

2003).

Figure (29): Inverted “V” columellar incision. Figure (30): “Stair-shaped” columellar incision (Adamson and Litner, 2009).

43


Necessary procedures are done on the nasal septum as regards its shape and

alignment. The surgeon has to be aware of the fact that the nasal septum is the

carrier of the whole cartilaginous part of the nose. For that reason, if nasal

resection is overdone or too little septal cartilage is left in the region of nasal

dorsum, nasal tip “drops” over the time and the profile line is lost (Kljajic et al.

2013).

The unique advantage of open techniques in comparison to the close ones is

that it is possible to correct bone and cartilaginous skeleton of the nasal pyramid

under eye control. It is very important in cases of inborn deformities or alar

cartilage weakness (Spielmann et al. 2009).

Figure (31): Exposed skeleton of the nasal pyramid after lifting of the nasal soft tissues.

Figure (32): A visible caudal part of nasal septum.

44


Osteotomies

Several techniques exist for performing osteotomies including medial, lateral

and transverse osteotomies. These can be performed via an external or internal

approach, depending on surgeon’s preference. Osteotomies are generally

performed for the following reasons:

To narrow the lateral walls of the nose.

To close an open-roof deformity (after dorsal hump reduction).

To create symmetry through straightening the nasal bony framework.

Contraindications include patients with short nasal bones, elderly patients

with thin and fragile nasal bones (Janis and Rohrich, 2007).

Lateral osteotomies may be performed as “low-to-high,” “low-to-low,” or as

a “double level” (Harshbarger and Sullivan 1999).

Figure (33): The various types of lateral osteotomies (Janis and Rohrich, 2007).

45


Furthermore, they may be combined with medial, transverse, or greenstick

fractures of the upper bony segment. Regardless of the technique used, it is very

important to preserve the webster triangle. It is a bony triangular area of the caudal

aspect of the maxillary frontal process near the internal valve and responsible for

it’s support. Preservation of this triangle prevents functional nasal airway

obstruction from internal valve collapse (Harshbarger and Sullivan 1999).

It is also vital to prevent a potential step-off deformity by maintaining a

smooth fracture line low along the bony vault. The cephalic margin of the

osteotomy should not be higher than the medial canthal ligament, as the thick nasal

bones above this area increase the technical difficulty and it is possible to cause

iatrogenic injury to the lacrimal system with resultant epiphora (Harshbarger and

Sullivan 1999).

Figure (34): Preservation of Webster triangle is paramount when performing lateral osteotomies to prevent internal nasal valve collapse (Janis and Rohrich, 2007).

46


A “low-to-high” osteotomy begins low at the pyriform aperture and ends

“high” medially on the dorsum, and is generally used to correct a small open roof

deformity or to mobilize a medium-wide nasal base. The nasal bones are then

medialized by a gentle greenstick fracture along predictable fracture patterns

obtained based on nasal bone thickness (Goldfarb et al. 1993).

Thicker nasal bones may require a separate superior oblique osteotomy in

order to mobilize them enough to be greensticked. A “low-to-low” osteotomy

starts low along the pyriform aperture and continues low along the base of the

bony vault to end up in a lateral position along the dorsum near the intercanthal

line. It is generally considered a more powerful technique in that it results in more

significant medialization of the nasal bones and therefore is classically used when

there is a large open-roof deformity or if a wide bony base requires correction. This

type of osteotomy technique is frequently accompanied by a medial osteotomy in

order to better mobilize the nasal bones to achieve the desired result (Sullivan et

al. 2002).

Figure (35): The course of a superior oblique medial osteotomy (Janis and Rohrich, 2007).

47


Medial osteotomies are used to facilitate medial positioning of the nasal

bones and are generally indicated in patients with thick nasal bones or wide bony

bases in order to achieve a more predictable fracture pattern. Although medial

osteotomies are frequently used in combination with lateral osteotomies, it is not

necessary to use both in all cases (Sullivan et al. 2002).

If both techniques are performed, the medial osteotomy is usually performed

first as this makes it technically easier to perform the subsequent lateral osteotomy.

It is also important to avoid placing the medial osteotomy too far medially as it

connects with the lateral osteotomy as this can cause a “rocker deformity”.

(Sullivan et al. 2002)

A double-level lateral osteotomy is indicated in cases where there is an

excessive lateral wall convexity that is too great to be corrected with a standard

single-level lateral osteotomy or when significant lateral nasal wall asymmetries

exist (Harshbarger and Sullivan 1999).

The more medial of the two lateral osteotomies is first created along the

nasomaxillary suture line. The more lateral of the two is then created in standard

low-to-low fashion (Harshbarger and Sullivan 1999).

Figure (36): “Rocker deformity” caused by placing the medial osteotomy too far medially (Janis and Rohrich, 2007).

48


Some of potential complications can occur with osteotomies (Janis and

Rohrich, 2007).

Figure (37): The double-level osteotomy. The medial-most one is made first (Janis and Rohrich, 2007).

Table (2): complications with osteotomies (Janis and Rohrich, 2007).

49

Techniques to Correct Deviated Cartilaginous Nasal Dorsum


The deviated dorsum may create functional and aesthetic issues that require

correction. It is a complex three-dimensional structure in which correcting a

functional issue may have an impact on cosmoses and cosmetic correction may

impair nasal function. Therefore, any attempt at straightening a dorsum should

achieve cosmetic outcome and maintain or improve nasal function. A proper

skeletal support is necessary to provide long term aesthetic and functional results.

(Gunther and Rorich, 1988)


resulting in loss of support, whereas the modern operations focus on restructuring

the nose (Tardy and Toriumi, 2000).

Autogenous cartilage is the material most commonly used to restructure the

nose and to provide support, augmentation and repositioning of the deviated

dorsum. The nasal septum, auricular conchal cartilage and costal cartilage can be

used (Zoumalan et al. 2009).

It is clear that the crooked nose constitutes a problem but in actual practice

what may appear to be a brilliant success immediately after surgery can be proved

a failure a few months later on the reappearance of the deviation to some degree.

This depends entirely on the cartilaginous structures of the nasal pyramid, which

retain the “memory” of the deviation due to their elasticity to regain their original

position over time like a spring (Boccieri and Camillo, 2013).

This phenomenon is due to tissue deforming forces of an extrinsic and

intrinsic nature that act on the cartilaginous nasal septum and cause relapse if they

50


are not released during surgery. These forces are deviated nasal bones, upper

lateral cartilages, the vomer and maxillary crest.

The intrinsic forces can be the result of an inherent tendency of the septal

cartilage to revert to its initial position (Sykes et al. 2011)

The difficulty in solving the problem of the crooked nose lies entirely in the

cartilaginous structure, especially the dorsal section of the nasal septum. While a

deviated nasal septum can in fact be largely removed from a functional standpoint,

it is necessary in any case to leave an L-shaped structure capable of supporting the

nasal pyramid as a whole. But also this structure must be modified, as the

deformity will otherwise remains present (Rohrich and Hollier, 2000).

Numerous techniques were described, involving the use of sections,

incisions and morselization to modify the cartilaginous portion of the dorsal pillar

of the septum (Schlosser et al. 1999).

Extracorporeal septoplasty, spreader grafts and the crossbar grafts are all


also in solving the functional problems (Boccieri and Camillo, 2013).

Extracorporeal septoplasty for correction of the severely deviated caudal

septum was first reported by Gubisch in 1995. He described complete removal of

the entire cartilaginous septum, then straightened and returned back to the nose.

(Gubisch, 1995)

In practical terms, the nasal septum is completely removed, reshaped and

straightened outside the nose, then replaced between the two mucoperichondrial

flaps and sutured into position inside the nose (Gubisch, 1995).

51


Figure (38): Extracorporeal septoplasty: (A) Removed nasal septum. Two healed fracture lines at sites of cartilage dislocation are evident. (B) Straight, reconstructed septum after excision of redundant dislocated cartilage. (C) The reconstructed straight septal plate before reinsertion. (Gubisch, 2005)

He described two areas of fixation to secure the newly reconstructed septum

back into the native nose. The first area of fixation is the caudal end of the nasal

bones, where the cephalic dorsal septum is reattached. He accomplished this by

suturing the reconstructed septum to the upper lateral cartilage or by placing a

transcutaneous U-suture (Gubisch, 1995).

The second point of fixation is the maxillary crest, where the posterior septal

angle is reattached. This is accomplished by drilling a hole through the nasal spine

and suturing the newly reconstructed neocaudal septum downward to the maxillary

crest (Gubisch, 1995).

Although this technique was highly effective for straightening a deformed

septum and replacing it in the nose to restore nasal function, it has been criticized

for being very technically demanding to execute. There was also a risk of aesthetic

complications, especially in the area of transition from the bony dorsum to the

reconstructed cartilaginous dorsum (D’Andrea et al. 2001).

52


In 2006, Most modified Gubisch’s technique to simplify the reconstruction

and decrease the aesthetic complications along the bony and cartilaginous dorsum.

He described excising almost all of the cartilaginous septum, preserving a 1.5-cm

dorsal septum remnant. Then he sutured the reconstructed septum to whichever

side of the dorsal remnant was more concave (Most, 2006).

Fixation in the area of the posterior septal angle to the nasal spine was

performed similarly as described by Gubisch. Most achieved functional results that

were excellent and he reported no aesthetic complications (Most, 2006).

Although Most simplified Gubisch’s technique still he relied on a

reconstructed septum of the original cephalocaudad length that had to be fixated to

the nasal spine with sutures. This can be a technically challenging and time

Figure (39):Fixation of the reconstructed septum: (A) Fixation on the spina nasalis anterior and on the lateral cartilage. (B) Fixation on the spina nasalis anterior and with transcutaneous U-shaped suture. (Gubisch, 2005)

53


consuming surgical step as the surgeon must bring special powered instruments to

drill a hole in the nasal spine (D’Andrea et al. 2001).

A new technique simplified the surgical maneuvers necessary for neoseptum

fixation. This technique described the fabrication of a longer neocaudal septum. By

longer, it imply a septum with a greater cephalocaudad length (Matt et al. 2011).

Gubisch and Most relied on the creation of a septum of similar length to the

native septum and both of their techniques made the surgeons to use complex

maneuvers to achieve stable midline fixation in the area of the nasal spine (Matt et

al. 2011).

The new technique eliminates this time consuming part of the procedure and

in exchange provides a method of stable midline caudal fixation that is reliable and

can be performed much more quickly (Matt et al. 2011).

After fabrication, the reconstructed neocaudal septum will span the

membranous septum and rest at the caudal edge of the medial crura. Not only the

airway is improved with a midline straightened septum, this also provides tip

support by creating a septum that extends to the medial crura and sutured with

transcutaneous horizontal mattress sutures. (Matt et al. 2011).

Figure (40): Neocaudal septum extending past the caudal border of the medial crura (Boccieri and Camillo, 2013).

54


Figure (41): Neocaudal septum trimmed (A) Lateral view of the neocaudal septum in a very caudal position. (B) Lateral view of the neocaudal septum flush with the medial crura. (C) Frontal view of the neocaudal septum (marked in blue ink) extending to the caudal border of the medial crura (Boccieri and Camillo, 2013).

Rather than trying to place buried permanent sutures, they found that 3 to 4

through-and-through 6-0 polydioxanone sutures are effective. It is important that

the entry spot of the 6-0 polydioxanone sutures along the vestibular skin of the

medial crura be very close to the exit point of the same suture. That way, only a

small amount of medial crura vestibular skin is under the knot. The suture is cut

right on the knot. Thus far, no patients have been aware of these transvestibular

skin sutures by suture extrusion or by the patient feeling the cut edges of the 6-0

polydioxanone sutures (Matt et al. 2011).

In summary, much midline stability is achieved with this suture fixation to

the medial crura without sewing to the nasal spine. By extending and fixating the

neocaudal septum to the medial crura stabilization of the neocaudal septum is

achieved. However, stabilization with two weeks of internal nasal splints is

recommended (Matt et al. 2011).

Considerable progress towards solving the problem of deviated nose came

with the use of spreader grafts that involves positioning of a rectangular strip of

55


cartilage on either side of the dorsal septum. This method served fundamentally to

strengthen the middle nasal vault during rhinoplasties and hence prevent post-

operative collapse (Boccieri and Camillo, 2013).

Spreader grafts are strut-shaped cartilage grafts, which are placed between

the anterior septal edge (septal roof) and the upper lateral cartilage, typically on

both sides the use of this technique initially described in 1984 (Wagner and

Schraven, 2011).

The internal nasal valve is the narrowest part of the nasal airway and its

cross-sectional area is determined by the angle formed between the caudal part of

the upper lateral cartilage and nasal septal cartilage. Spreader grafts play a role in

the treatment of nasal valve collapse by widening the nasal valve angle and

maintaining the widened angle with variable degrees of success (Wittkopf et al.

2008).

Figure (42): An illustration demonstrating spreader grafts that are placed and fixed in position with 5-0 polyglactin (Guyuron et al. 2012).

56


Figure (43): C-shaped deviation of the dorsal septum and its correction using a spreader graft on the concave side (Boccieri and Camillo, 2013).

Spreader grafts are usually linear strips of autologous cartilages. They are

usually harvested from septal cartilage and shaped in rectangular bars,

approximately 2-3 cm long, 3-5 mm wide and 1.5 mm thick. Auricular cartilage

from cavum concha can also be used as spreader graft (Reivel et al. 2011).

A spreader graft on the concave side in C-shaped deviations is inserted to

restore the respiratory function and to harmonize the aesthetic line from the brow

to the nasal tip. In cases of linear deviation of the nasal pyramid, it is necessary to

position the spreader graft on the side opposite the deviation, where there is a gap

between the septum and the upper lateral cartilages. In both cases, the use of

spreader grafts makes it possible to secure a lasting correction of the deviation and

camouflage any residual crookedness (Boccieri and Camillo, 2013).

Another study showed that it is possible to correct nasal deviation using the

spreader graft on the convex side of the septum whenever it is possible to

recognize the deviation is C- shaped and identify the convex side (Deoliveira et al.

2006).

While Rohrich also supports the technique of the unilateral spreader graft,

Guyuron advocates the use of bilateral spreader grafts to counter the cartilaginous

memory more firmly (Sykes et al. 2011).

57


Use of an open approach makes it easy to suture the upper lateral cartilages

to the septum and the spreader grafts previously placed in position. This last phase

of the operation is important and should always be carried out to avoid curling of

the upper lateral cartilages and associated post-operative deformity. While spreader

grafts can be inserted in both a closed and open approach, the latter provides a

clearer view of nasal structures and makes it possible to position and secure

spreader grafts with greater ease and precision (Boccieri and Camillo, 2013).

The septal extension graft, first introduced by Byrd et al. in 1997. It

constitutes fixing a graft on the caudal or dorsal septum between both of the lower

lateral cartilages while controlling nasal lengthening and tip projection, rotation

and shape. (Byrd et al. 1997).

Basically, the septal extension graft is formed by fixing the septum through a

septal angle, extending to the interdomal space. The distal portion of the graft,

forming an appropriate supratip break, is made through a three-point fixation at a

lower lateral cartilage along with tip position as needed (Byrd et al. 1997).

Figure (44): The distal portion of the graft, forming an appropriate supratip break, is made through a three-point fixation at a lower lateral cartilage along with the tip position as needed (Kim et al. 2014) .

58


Furthermore, a specific procedure for fixing the proximal portion to the

septum according to the shape and direction is the paired spreader type in which a

graft inserted between the upper lateral cartilage and the dorsal septum via a

spreader graft, extending over the caudal margin. This correction can reinforce a

weak midvault and lateralize the upper lateral cartilage, resulting in the widening

of the internal valve (Kim et al. 2014).

A surgical protocol to correct crooked nose adopted an open approach to the

nasal pyramid, where a small columellar incision makes it possible to view all of

the anatomical structures and suture the grafts precisely in position. This approach

forms the background to a technique known as “septal crossbar graft” (Boccieri

and Pascali, 2003).

The crossbar and spreader grafts share the same underlying philosophy,

being both designed to strengthen and support the dorsal nasal septum (Boccieri

and Pascali, 2003).

Figure (45): The paired spreader technique (Kim et al. 2014).

59


While the septal crossbar graft can be regarded as an intra-septal spreader

graft, it makes it possible to double the space between the septum and the upper

lateral cartilages compared to a single spreader graft. The septal crossbar graft is

particularly useful in the correction of severe septal deviation and ensures the

greatest degree of resistance to cartilaginous memory. In practical terms, it can be

indicated when the distance of the point of greatest deviation of the nasal pyramid

from the median line is more than 5 mm long (Boccieri, 2006).

In practice, a rectangular graft of cartilage taken from a straight portion of

the septum is embedded in the dorsal septum like a bar behind a door to prevent

opening from the outside. The surgical technique involves the execution of a

classical septoplasty, leaving in place an L-shaped structure of at least 15 mm in

thickness, and harvesting a straight strip from the septum about 3-6 mm in height

(Boccieri, 2006).

Before insertion of the graft, it is necessary to make a series of incisions in

the dorsal and caudal pillars of the L-shaped structure. Three incisions can be made

for each of the two pillars, one on the inside and two on the outside at the points of

greatest deviation (Boccieri, 2006).

Figure (46): Diagrams for the correction of crooked nose using the septal crossbar graft (Boccieri and Camillo, 2013).

60


The next phase is insertion of the crossbar graft between the two incisions of

the dorsal pillar on the concave side of the deviation. This technique has proved to

be effective in many cases of crooked nose (Boccieri, 2006).

Also, the crossbar graft serves to open the internal nasal valve, which is

collapsed on the concave side which provides functional benefit for nasal

respiration (Boccieri, 2006).

Figure (47) Dorsal deviation of the septum and its correction with a crossbar graft (Boccieri and Camillo, 2013).

Figure (48): (A) Schematic diagram showing the depression of the upper lateral

cartilage on the concave side. (B) Intraoperative photograph showing lateralization of the left upper

lateral cartilage obtained with a septal crossbar graft (Boccieri and Camillo, 2013).

61


Because of the challenge faced with the problem of deviated nose, new

techniques described to fix this problem involving different sutures taken with

insertion of grafts to achieve better aesthetic results with least complications.

Through an open approach, the upper lateral cartilages are detached from the

septum, the septum is exposed dorsally and is excised leaving a 10-mm dorsal and

caudal strut. Then the septum is repositioned in the midline via either a suture to

the nasal spine or with a “swinging-door” flap and suture fixation. Medial and

lateral osteotomies are performed (Pontius and Leach, 2004).

At this point, one or more than one of the following techniques are used,

depending on the abnormality found:

The sidewall-spreading suture (Figure 49) is used on the side with a

depressed or concave upper lateral cartilage. It consists of a horizontal mattress

suture of 4-0 polydioxanone extending from the periosteum of the nasal bone to the

upper lateral cartilage (Pontius and Leach, 2004).

As the suture is tightened, it causes the upper lateral cartilage to flare

laterally and places the nasal bone and upper lateral cartilage in proper alignment

(Pontius and Leach, 2004).

Figure (49): The sidewall-spreading suture (Pontius and Leach, 2004).

62


The triangular spreader graft (Figure 50) is especially useful after the

sidewall-spreading suture has been placed on an atrophic upper lateral cartilage

creating a gap between the upper lateral cartilage and the septum. It is carved in a

triangular shape and is secured in the space between the septum and upper lateral

cartilage with 4-0 polydioxanone sutures (Pontius and Leach, 2004).

.

Clocking sutures (Figure 51) bring the lower third of the nose into

alignment with the upper two thirds. Clocking sutures of 4-0 polydioxanone are

placed caudocephalically on the convex side and cephalocaudally on the concave

side between the septum and upper lateral cartilages. When the sutures are

tightened, they unfurl the dorsal septum and secure it in the midline (Pontius and

Leach, 2004).

Figure (50): The triangular spreader graft (Pontius and Leach, 2004).

Figure (51): The clocking sutures (Pontius and Leach, 2004).

63


Septocolumellar sutures (Figure 52) are used in cases where residual caudal

septal bowing remains. The caudal septum is scored on the concave side and is

secured to an extended columellar strut. The caudal septum is fixed to the strut

with multiple simple sutures of 4-0 polydioxanone (Vuyk, 2000).

Excision of a “Burow triangle” of cartilage (Figure 53) can be used when

the residual caudal and dorsal struts of septal cartilage are straight except for

residual bowing in the “elbow” area. For this technique, the caudal and dorsal

struts are sharply divided and the overlapping triangle of cartilage is excised. The

caudal and dorsal struts are then reapproximated with 4-0 polydioxanone sutures,

and the bowing is eliminated (Vuyk, 2000).

Figure (52): Septocolumellar sutures (Pontius and Leach, 2004).

Figure (53): Excision of a “Burow triangle” of the septal cartilage (Pontius and Leach, 2004).

64


In cases of severe cephalocaudal convexity of the dorsal L-strut, surgeons

found that it is difficult to correct the deviation without breaking the cartilage

spring action by performing cuts at certain points that show maximal convexity

and augmenting the cartilage with grafts in order to achieve a straight and strong

nasal septum.

Through an open approach with a transcolumellar inverted V-shape incision

was connected to a bilateral marginal incision. The cartilaginous and bony septum

is harvested, leaving at least 1 cm of the L-strut. Spreader grafts are used in cases

of severe deflection of the dorsal L-strut. If straightening could not be achieved,

the mid-section of the dorsal L-strut is cut, and overlapping 5-0 PDS

(polydioxanone) sutures were positioned (Song et al. 2008).

Figure (54): Dorsal L-strut cutting and suture technique. (A) Severe cartilaginous dorsal deflection. (B) Resection of septal cartilage while maintaining L-strut. Correction of dorsal

L-strut curvature can result in decreased nasal length and increased cephalic rotation of caudal septum. Dotted line indicates L-strut position before it was cut.

(C) Cutting bent area of L-strut and then reconnecting it using overlapping 5–0 PDS suture.

(D) Spreader graft can be used to straighten and maintain supporting structure of nasal septum. Septal extension graft can be used to compensate for shortening and cephalic rotation of dorsal L-strut

(Song et al. 2008).

65

Patients & Methods

Patients & Methods

This study was conducted on 60 patients complaining of deviated nose with

cartilaginous dorsal deviation attending The Outpatient clinic, ENT department,

Kasr Alainy hospital in the period between January 2012 and January 2014.

The study was approved by the scientific and ethical committee of our

institution.

Study Population:

60 patients were included in this study:

Group A: 30 patients who underwent “dorsal L-strut cutting and suture technique

and spreader grafts.

Group B: 30 patients previously operated with the use of spreader grafts only.

Inclusion criteria:

Crooked nose (involving the cartilaginous dorsum) with or without lower

third deformity.

Exclusion criteria:

-Isolated dorsal bony deformity was excluded.

-Any patient who had previous rhinoplasty or septal surgery was excluded.

66

Patients & Methods

All patients were subjected to the following:

Preoperative patient selection and assesment:

• A detailed history which is very important step in the evaluation of every

patient presenting with deviated cartilaginous dorsum of the nose including:

History of trauma - Present. - Absent.

Headache. Epistaxis:

- Abcsent. - Present:

Severity. Predisposing factors.

Allergic symptoms: sneezing, itching and rhinorrhea. Resonance of voice through auditory perceptual assessment of voice. Nasal obstruction:

- Absent. - Present:

Unilateral or Bilateral. Persistant or intermittent. Responding to medical treatment (local and systemic

decongestants) or not. previous rhinoplasty and or septal surgery was taken.

• Physical examination is done for every patient concerning: Type of deviation? Associated malgrowth of lower alar cartilage and/or another deformity? Associated nasal obstruction is it nasal valve problem, turbinate

hypertrophy, nasal polyps or deviated septum?

• All the data obtained from the history and physical examination are collected in the following sheet.

67

Patients & Methods

Table (3): History and examination sheet (Tebbetts, 2007).

68

Patients & Methods

Photography:

Three aspect photography: frontal, Basal and lateral (right & left) views.

Preoperative:

Patient’s consent was obtained prior to undergoing the surgical procedures.

Intraoperative:

Correction of deviated cartilaginous dorsum was done using combination of the “dorsal L-strut cutting and suture technique” and spreader grafts.

Surgical Procedure: Through an open approach with V-shape columellar incision connected to a

bilateral marginal incision.

Figure (55): Preoperative photography views.

Figure (56): “V” Shape incision of the open approach.

69

Patients & Methods

The osseocartilaginous skeleton was exposed, and the septal mucoperichondrial flaps were elevated, beginning at the anterior septal angle.

The septum was freed from the extrinsic forces of the deformed nasal bones and from the upper and lower lateral cartilages.

The nasal septum was harvested, leaving at least 1 cm L-strut. Any remaining deviations in the caudal and dorsal part of the septum were

then assessed. The mid-section of the dorsal L-strut was cut and overlapping 5-0 Prolene

sutures were positioned.

Figure (57): Exposure of the osseocartilaginous skeleton.

Figure (58): Dissection of the septum.

70

Patients & Methods

Spreader grafts were then used in all cases to support the dorsal L-strut and to maintain the straightening.

Apart from correcting dorsal deformities, any caudal L-strut deformities

were corrected by dividing the connection with the anterior nasal spines, removing excess cartilage, and fixing them securely in position.

Other surgical procedures were used when necessary including columellar strut or tip grafts.

Medial and lateral osteotomies were performed.

Figure (59): Sparing “L” strut of the septum. Figure (60): L-strut cutting and suture technique.

Figure (61): Insertion of spreader graft.

71

Patients & Methods

Table (4): The operative data sheet (Tebbetts, 2007).

72

Patients & Methods

Upon discharge each patient was handled the following postoperative instructions:

73

Patients & Methods

All the instructions in the previous table were given in Arabic to the patients as following.

Table (5): postoperative instructions (Tebbetts, 2007).

74

Patients & Methods

75

Patients & Methods

After discharge:

External nasal splint removed after 1 week. Internal nasal stent removed after 10 days.

Table (6): postoperative instructions in arabic.

76

Patients & Methods

Photography: Postoperative regular follow up photography was conducted for at least two

month. Preoperative and postoperative photographs were studied to evaluate surgical outcome.

Figure (62): Reassurance of patients developed edema and ecchymosis in the postoperative period.

Preoperative 1 month postoperative 3 month postoperative 6 month postoperative

Figure (63): postoperative follow up photography.

77

Patients & Methods

Assessment of Outcomes and Complications

Assessment of deviation improvement was based on: Comparisons between the preoperative photograph and the postoperative

photograph taken at the final follow-up. According to this, Outcomes were classified as: - 0 = No change. - 1 = Fair. - 2 = Good. - 3 = Excellent.

Subjective analysis for aesthetic score using Visual Analogue Scale (VAS) for their symptom. Aesthetic scores are plotted from 0 to 4 for subjective improvement; where: - 0 = no improvement. - 1 = mild improvement. - 2 = moderate improvement. - 3 = good improvement. - 4 = excellent improvement.

Postoperative histories were reviewed to assess complications, including postoperative infection, postoperative deformity (e.g., saddling or notching), incomplete correction, recurrence of deviation and loss of tip support or projection.

All the results were tabulated and statistically analyzed

78

Results

Results

This study included 60 patients with dorsal cartilaginous nasal deviation.

There were 12 females and 48 males. Patients ranged in age between 18 to 46

years.

Group A:

This group included 30 patients with nasal deviation treated with the use of L-

strut cutting and suture technique in combination with spreader graft. This group

included 25 males and 5 females with age ranges from 18 to 46 years [Mean age

=26.9 with standard deviation= 6.3].

Range Mean ± SD Median (IQR)

Age (years) 18 – 46 26.9 ± 6.3 26.0 (22.8 – 30.0)

Before treatment

Those patients had different complaints. Seventeen patients were

complaining of cosmetic disfigurement (56.7 %), eight patients with nasal

obstruction (26.7%), two patients with headache (6.7%), two patients with allergic

symptoms (6.7%) and one patient with epistaxis (3.3%).

After history taking and examination, 24 patients (80%) showed history of

trauma, 19 patients (63.3%) with deviated septum and 11 patients (36.7%) showed

displaced septum.

Table (7): age range in group A.

79

Results

Frequency (n=30) Percentage Sex

Male 25 83.3 Female 5 16.7

Main complaint Cosmetic Disfigurement 17 56.7 Headache 2 6.7 Nasal obstruction 8 26.7 Epistaxis 1 3.3 Allergic 2 6.7

History of trauma No trauma 6 20.0 There was trauma 24 80.0

Septum Deviated 19 63.3 Displaced 11 36.7

After treatment

The postoperative VAS-Cosmetic results showed that six patients were

moderately improved (20%), 10 patients showed good improvement (33.3%) and

14 patients (46.7%) with excellent improvement.

By examination, only three patients showed no improvement of nasal

septum misalignment (10%) and 27 (90%) patients showed central septum.

There were three patients developed nasal synechea (10%) and one patient

(3.3%) with subcongunctival hemorrhage.

On comparison between the preoperative and postoperative photographs

there were six patients with fair improvement (20%), 13 patients (43.3%) with

good improvement and 11 patients (36.7%) with excellent improvement.

Table (8): history and examination in group A.

80

Results

On comparison between the results obtained from the photographic

assessment and that from patient satisfaction we found that it is statistically highly

significant, indicating that patient satisfaction is greater than expected from the

photographic assessment.

Photograph Fair

(n=6) Good (n=13)

Excellent (n=11)

P value

N % N % N % VAS

Moderate improvement

6 100.0 0 0.0 0 0.0 <0.001*

Good improvement 0 0.0 10 76.9 0 0.0 HS Excellent improvement 0 0.0 3 23.1 11 100.0

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Fair Good Excellent

Photograph

100.0%

0.0% 0.0%0.0%

76.9%

0.0%0.0%

23.1%

100.0%VAS with Photograph for group A

Moderate improvement Good improvement Excellent improvement

Table (9): comparison between photographic assessment and patient satisfaction in group A.

Figure (64): comparison between photographic assessment and patient satisfaction in group A.

81

Results

Group B:

This group included 30 patients with nasal deviation treated with the use of

spreader graft. This group included 23 males and 7 females with age ranges from

19 to 45 years [Mean age =29.1with standard deviation= 5.7].

Range Mean ± SD Median (IQR) Age (years) 19 – 45 29.1 ± 5.7 28.0 (25.8 – 34.0)

The postoperative VAS-Cosmetic results showed that two patients (6.7%)

with no improvement, three patients (10%) with mild improvement, five patients

were moderately improved (16.7%), 9 patients showed good improvement (30%)

and 11 patients (36.7%) with excellent improvement.

On comparison between the preoperative and postoperative photographs

there were two patients (6.7%) with no improvement, five patients with fair

improvement (16.7%), 14 patients (46.7%) with good improvement and 9 patients

(30%) with excellent improvement.

On comparison between the results obtained from the photographic

assessment and that from patient satisfaction we found that it is statistically highly

significant, indicating that patient satisfaction is greater than expected from the

photographic assessment.

Table (10): age range in group B.

82

Results

Photograph No change Fair Good Excellent P value N % N % N % N % VAS

No improvement 1 50.0 1 20.0 0 0.0 0 0.0 <0.001* Mild improvement 1 50.0 2 40.0 0 0.0 0 0.0 HS Moderate improvement 0 0.0 0 0.0 5 35.7 0 0.0 Good improvement 0 0.0 0 0.0 0 0.0 9 100.0 Excellent improvement 0 0.0 2 40.0 9 64.3 0 0.0

On comparison between both groups regarding demographics, the age and

sex weren’t statistically significant. Furthermore, deviated or cocked nose is more

common in males than females and also common in young age group.

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

No change Fair Good Excellent

Photograph

50.0%

20.0%

50.0%

40.0% 35.7%

100.0%

40.0%

64.3%

VAS with Photograph for group B

No improvement Mild improvement Moderate improvement

Good improvement Excellent improvement

Table (11): comparison between photographic assessment and patient satisfaction in group B.

Figure (65): comparison between photographic assessment and patient satisfaction in group B.

83

Results

* Fisher’s exact test, # independent sample t-test

Group A (n=30) Group B (n=30) P value Sexn,%

Male 25 (83.3%) 23 (76.7%) 0.7* Female 5 (16.7%) 7 (23.3%) NS

Age (years)Mean ± SD 26.9 ± 6.3 29.1 ± 5.7 0.2# NS

Table (12): Comparison between both groups regarding demographics is statistically insignificant.

Figure (66): Comparison between both groups regarding sex.

Figure (67): Comparison between both groups regarding age.

84

0.0%20.0%40.0%60.0%80.0%

100.0%

Group A Group B

83.3% 76.7%

16.7% 23.3%

Sex distribution in both groups

Male Female

0

10

20

30

40

Group A Group B

26.9 29.1

Mean age

Results

On comparison between both groups regarding VAS cosmetic results, we

found that the results were not statistically significant (P value = 0.2). Although

that the postoperative VAS-Cosmetic results of good and excellent improvement in

group (A) was 78% compared to 66.7% in group (B).

Also on comparison between both groups regarding the assessment of

preoperative and postoperative photography, we found that the results were not

statistically significant (P value = 0.5). Although that the patients showed good and

excellent improvement were 80% in group (A) compared to 76.7% in group (B).

Figure (68): Comparison between both groups regarding visual analogue scale (VAS).

85

Results

Group A (n=30) Group B (n=30) P value N % N % VAS

No improvement 0 0.0 2 6.7 0.2* Mild improvement 0 0.0 3 10.0 NS Moderate improvement 6 20.0 5 16.7 Good improvement 10 33.3 9 30.0 Excellent improvement 14 46.7 11 36.7

Photograph No change 0 0.0 2 6.7 0.5* Fair 6 20.0 5 16.7 NS Good 13 43.3 14 46.7 Excellent 11 36.7 9 30.0

* Chi square test

Table (13): Comparison between both groups regarding VAS & photograph.

Figure (69): Comparison between both groups regarding photographic assessment.

86

Results

The following are examples of patients whose results considered good and excellent.

Figure (70): Female patient 28 years old with no history of trauma. (A), (B) & (C) are the pre-operative pictures. (D), (E) & (F) are the post-operative pictures.

87

Results

Figure (71): Male patient 22 years old with history of trauma. (A), (B) & (C) are the pre-operative pictures. (D), (E) & (F) are the post-operative pictures.

88

Results

Figure (72): Male patient 19 years old athletic with history of trauma. (A), (B) & (C) are the pre-operative pictures. (D), (E) & (F) are the post-operative pictures.

89

Results


90

Results

Figure (74): Male patient 34 years old with no history of trauma. (A), (B) & (C) are the pre-operative pictures. (D), (E) & (F) are the post-operative pictures.

91

Results


92

Results


93

Results


94

Results


95

Results

Figure (79): Female patient 37 years old with no history of trauma. (A), (B) & (C) are the pre-operative pictures. (D), (E) & (F) are the post-operative pictures.

96

Results


97

Results

The following are examples of patients with fair results.


98

Results

Figure (82): Male patient 21 years old boxer with history of trauma. (A), (B) & (C) are the pre-operative pictures. (D), (E) & (F) are the post-operative pictures.

99

Results


100

Results


101

Results

Figure (85): Female patient 45 years old with history of trauma. (A), (B) & (C) are the pre-operative pictures. (D), (E) & (F) are the post-operative pictures.

102

Discussion

Discussion




unit (Gubisch, 2005).

A crooked nose may be congenital or acquired. The acquired crooked nose is

more common and typically caused by trauma. These deformities are usually due

to a set of anatomical abnormalities and result in aesthetic and functional problems.

(Teymoortash et al, 2012)

From history, our study confirmed that trauma is the leading cause of

crocked nose (80% of cases with history of trauma). That’s why; this study

confirmed from the age and sex demographics of the patients that the crocked nose

is very common among males and young age groups.

The septum and the nasal bones control the direction of the nose. Thus,

deviation of the nose can result from misalignment of one or the other or a

combination of both (Most, 2006).

From the examination, our study found that with cases of crocked nose there

is always misalignment between the cartilaginous septum and its bony grove in the

maxillary crest either in the form of deviation (63.3%) or dislocation (36.7%).

During septorhinoplasty to reconstruct the deviated nose, both lateral and

medial nasal osteotomies are carried out so that the deviated septum can be

disconnected from its bony attachments for easy repositioning at the midline (Song

et al. 2008).

103

Discussion


resulting in loss of support, whereas the modern operations focus on restructuring

the nose (Tardy and Toriumi, 2000).

In actual practice what may appear to be a brilliant success immediately

after surgery can be proved a failure a few months later on the reappearance of the

deviation to some degree. This depends entirely on the cartilaginous structures of

the nasal pyramid, which retain the “memory” of the deviation due to their

elasticity and the tendency to revert to their original position over time like a

spring (Boccieri and Camillo, 2013).

Techniques such as scoring and thinning are used for straightening or

repositioning the deviated dorsal septum. Sutures, bone or cartilage battens are

used for maintaining these changes (Song et al. 2008).

Although these techniques are relatively noninvasive and quick, sometimes

they become not appropriate to correct severe cartilaginous deviation because they

can’t counter the cartilage memory or the inherent tensile forces that can cause

later on recurrence of the deviation (Song et al. 2008).

For that reason extracorporeal septoplasty was invented not only for

correction of the severely deviated caudal septum but also to overcome the

cartilage memory.

It was first reported by Gubisch (1995). He described complete removal of

the entire cartilaginous septum, then straightening and fixing it in position through

a burr hole in the nasal bones posteriorly and the nasal spine anteriorly.

104

Discussion

Gubisch (2005) described a retrospective medical chart review of patients

underwent extracorporeal septoplasty from January 1981 to July 2004. He operated

on 459 patients, while residents operated on 108 patients under his supervision.

A good to excellent functional and asthetic results were obtained in 96% of

patients with 12% complications occurred. The most common complaint was

irregular contour of the dorsum.

Andre´ and Vuyk (2006) evaluated 114 patients underwent surgery for

crocked nose through an open approach between 1995 and 2004.

Forty five patients were treated as Gubisch (2005) described and the

remaining 69 patients were treated with septal batten insertion and fixation to the

septum (after its straitening by scoring or thinning of the septum on the concave

side of the deformity or a series of complete cuts through the septum was done) to

maintain the straightening achieved and to provide structural support.

They found that the overall improvement rate was 94% in the first group

which is nearly equal to the results obtained by Gubisch (2005) compared to 86%

in the septal batten group.

Although extracorpoereal septoplasty technique achieved good results it is

still criticized as being difficult and long procedure. Furthermore, it may cause

asthetic complications and jeopardizes the integrity of the keystone area. Also the

surgeon must bring special powered instruments to drill a hole in the nasal spine

and the nasal bones.

Matt and Mobley (2011) simplified Gubisch’s (2005) technique by making

the fabricated septum spaning to the membranous septum and suturing it to the

medial crurae and applied it to forty-six patients who underwent surgery from June

105

Discussion 2007 to April 2010. They reported that 91% showed improvement and only four

patients (9%) experienced complications.

Still their method can be a technically challenging and time consuming

surgical procedure and also needs enough and good experience to achieve good

asthetic and functional results.

Jang and Kwon (2010) performed a retrospective study involved 27 patients

underwent another modified technique for extracorporeal septoplasty between June

2006 and January 2009.

In their study the dorsal and the caudal aspect of the newly created septal

cartilage L-strut were both fashioned into Y-shape by suturing cartilage strips to

the existing L-strut and sandwiched both the preserved cartilage tail at the keystone

area and the anterior nasal spine and sutured to them.

The cosmetic outcomes indicated that 89% of patients were satisfied.

Excellent in one case (4%), good in 23 cases (85%). Five patients complained of

stiffness and pain in the tip area. However their study has some limitations, such as

a relatively small number of patients with no control treatment group.

Several authors mentioned how spreader grafts may help in straightening the

crooked nose. Byrd et al (1998) described the use of cartilage grafts to reinforce

and to straight the middle third of the nose. The technique extends the use of

traditional spreader grafts from only being used in treatment of nasal valve stenosis

to correction of nasal dorsal deviation. Terkonda and Sykes (1999) mentioned

using cartilaginous or bony struts along the dorsum for the same purpose. They

used a drill to fashion suture holes in the ethmoid bones to increase suture stability

of these grafts.

106

Discussion

Boccieri et al. (2005) evaluated 60 patients who underwent spreader graft

insertion, 26 of them with crocked nose deformity from January 1999 to January

2002.

The spreader grafts were generally 1 to 3 mm in thickness, 3 to 6 mm in

height and 10 to 25mm in length; they were attached to the septum by means of

mattress sutures.

In the patients with crooked nose, there were no cases of reappearance of the

nasal deformity or of collapse of the middle nasal vault. Also no impairment of

nasal airflow was registered in the cases of preoperative normal breathing.

They concluded that the use of spreader grafts performs the dual function of

strengthening and guiding the “L” strut while countering cartilage memory over

time. Moreover, spreader grafts play a useful role in the treatment of nasal valve

collapse by widening the nasal valve angle thus preventing its collapse.

Furthermore they found that the open technique obviously provides a clearer

view of the nasal structures than closed technique while making the placement and

attachment of the spreader grafts easier and more precise.

In our study we operated on 30 patients using spreader graft technique to

correct their deviation. We used the traditional spreader graft as described by

Boccieri et al. (2005) through an open approach rhinoplasty technique. They were

attached to the septum by means of mattress sutures. Bilateral spreader grafts were

used to support the septum in straight position. In all patients, medial and lateral

osteotomies were performed before the placement of the grafts.

107

Discussion

We noticed on comparison between the preoperative and postoperative

photographs there were 76.7% good and excellent improvement with 83.4% of the

patients were satisfied.

However our results are nearly equal to those obtained from Scattolin et al.

(2013) who reported that 49 patients were submitted to “closed” approach

rhinoplasty with endonasal placement of a custom-made spreader graft (named

“rail spreader”) for the correction of crooked nose between 2007 and 2011.

The spreader graft system was prepared with a cartilage base shaped as a

trapezoid and two strips of cartilage graft were molded and sutured symmetrically

along the lateral edges of the base inferior surface, thus giving the graft the shape

of two rails connected to a cartilaginous base and separated by a groove. Each strip

graft is fixed to the cartilage base using two stitches.

At the postoperative follow-up, improvement in nose scores was found in

76.79% of cases.

Also our results mimic those obtained from Okur et al. (2004) who operated

on 27 patients with crooked noses through an open approach between May 2001

and November 2003 using spreader grafts and columellar struts to correct dorsal

nasal deviation.

They found that the I-type crooked noses had good or excellent results in

78.6% of cases. But in the C-type crooked noses the results showed only 53.8%

improvement. The low results obtained from patients with C-shape deformity

augments the concept which states that the surgeons must break the point of dorsal

deviation of the septum in order to cut the spring action and to maintain the

straightness achieved in the septum.

108

Discussion

Erdem and Ozturan (2008) described 120 cases underwent nasal surgery

through an open approach between May 1998 and June 2006.

Surgical methods have been utilized to correct the crooked nose deformity,

as insertion of bilateral and unilateral spreader grafts, total septal reconstruction, a

tongue-in-groove technique and camouflage techniques to the dorsum in addition

to reorientation methods. Good and excellent results were achieved in only 58.32%

of patients.

Their results were inferior to ours because they used different and separate

techniques in their patients without comparing between them individually.

An important limitation of spreader grafts is the need for an adequately long

enough and straight cartilage grafts which may not be able to be harvested from the

septal cartilage, especially in cases of secondary rhinoplasty or after septoplasty.

For that reason Gürlek et al. (2006) performed a study on 20 patients with

crooked noses using custom-made high-density porous polyethylene extended

spreader grafts to correct their deformities.

During a mean follow-up period of 18 months there were no complications,

recurrences or extrusions. Functional evaluation was performed using a visual

analog scale before surgery and 6 months after surgery. The mean postoperative

improvement was 88.75%.

Another study on the use of high-density porous polyethylene extended

spreader grafts conducted by Mendelsohn (2005) on 41 patients complaining of

crocked nose deformity between March 2002 and March 2004. He achieved almost

the same results.

109

Discussion

They all concluded that the use of custom-made high-density porous

polyethylene extended spreader grafts is a safe, effective, reliable and a permanent

method for correction of the crooked nose. Also, in the long term the graft

provided functional recovery and increased strength against further trauma and has

the ability to prevent recurrence attributable to cartilage memory.

Pontius and Leach (2004) performed a study on 79 patients in their private

practice who underwent corrective surgery for twisted-nose deformity from 1993

to 2003.

Through an open rhinoplasty approach they performed new technique to

correct dorsal deviation of the nose. Starting by the sidewall-spreading suture

which if tightened, it causes the upper lateral cartilage to flare laterally then

placement of the triangular spreader graft and after that they applied clocking

sutures to bring the deviated part of the nose into alignment with the rest of it.

They stated that all patients noted improvement, only 7 (8.86%) patients

noticed persistent deviation after surgery on anterior view.

However, in their study they didn’t mention a scoring system in the

evaluation and if the evaluation either subjective by patients or the surgeons

opinion or objective through the use of anthropometric measurements in their

assessment. Also there was no control group to compare their results with.

Esmen (2008) performed a study on 12 patients with crocked noses using

nasal bone grafts harvested from the removed nasal hump.

During a mean follow-up period of 20 months there were no complications,

recurrences or extrusions. The mean postoperative improvement was 89.88%.

110

Discussion

In cases of severe cephalocaudal convexity of the dorsal L-strut, it is

difficult to correct the deviation with spreader grafts only without breaking the

cartilage spring action and removing excessive cartilage. For that, our study

focused on the dorsal L-strut cutting and suture technique to correct severe

cartilaginous nasal deviation.

That’s why, apart from correcting dorsal deformities, it was very important

to address the septum and any caudal L-strut deformities were corrected by

dividing the connection with the maxillary crest and/or anterior nasal spines with

removing excess cartilage and fixing them securely in position straitened to treat

the crocked nose deformity.

In our study we found that when the septum was freed from the extrinsic

forces of the deformed nasal bones and from the upper and lower lateral cartilages,

then cutting the dorsal L-strut at a particular location, and overlapping sutures

applied allows good centralization and straightening of the crooked nose and

increases cephalic rotation of the nasal tip.

Furthermore, spreader grafts placement in all cases on both sides slightly

extending beyond the anterior septal angle with sometimes insertion of septal

extension graft was done to support the dorsal L-strut and to compensate well for

it’s shortening.

This technique overcomes cartilaginous memory through cutting the mid-

section of the dorsal septum and then reconnecting it using an overlapping suture

without jeopardizing the integrity of the keystone area.

111

Discussion

Our study found that the dorsal L-strut cutting and suture technique resulted

in 80% of patients showing excellent or good outcomes in comparisons made for

the preoperative and postoperative photographs.

Literature reports of success rates of this technique are difficult to quantify

or compare because of different surgical techniques and the lack of a uniform

objective reporting method.

We found that our results are similar to a study conducted by Song et al.

(2008). There were 27 patients who received the cutting and suture technique of

the deviated dorsal L-strut with grafting to control a severe cartilaginous dorsal

deflection between February 2004 and September 2006.

The postoperative assessments showed that 81.5% of patients had

“excellent” or “good” deviation correction. 7.4% patients experienced cephalic

rotation of the tips and shortening of the nasal length. There were no reports of

recurrence, saddling, or infection during follow-up.

Also there was a study performed by Jang et al. (2009) on 23 patients with

dorsal nasal deviation using L-strut graft method that approached our results. They

reported that the outcome of surgery was excellent and good in 78% of cases.

In a similar study to ours conducted by Ghiasi et al. (2013) they evaluated

40 patients with nose deviation underwent open rhinoplasty approach between

2009 and 2011. The cases were selected and divided randomly according to the

technique used into spreader graft and L-strut graft groups.

Evaluation of deviation intensity in patients was mild, moderate or severe.

The outcome obtained after surgery based on comparison between preoperative

112

Discussion and postoperative photography was evaluated as no change, average, good or

excellent.

In the L-strut graft technique group, after complete skeletonization of septal

cartilage, the cartilaginous septum was harvested leaving at least 1 cm of the L-

strut. Then, the caudal and dorsal deviation line of the L-strut is modified by

cutting and suturing then insertion of the graft was done to support the dorsal L-

strut and to maintain the straightening. Medial and lateral osteotomies were

performed in all cases.

The outcome after surgery in patients with severe deviation in L-Strut

technique group was significantly better (100% excellent and good results)

compared to the spreader technique group (54.5% excellent and good results).

While the outcome of surgery in patients with moderate deviation the

previous significant difference become less then become insignificant in patients

with mild deviation.

However there results may appear different than ours, but this difference is

due to their classification of patients according to the severity of the deviation. For

that they found that L-strut graft technique is very helpful in severe cases, but the

difference is not that significant in moderate and mild cases of deviation which is

similar to our results because the majority of our patients were complaining of

moderate and mild deviation.

Although this study was limited by the small number of patients and a

relatively short follow-up period, the surgical outcomes indicated that the dorsal L-

strut cutting and suture technique is an effective method for correcting severe cases

of cephalocaudal convexity of the dorsal L-strut.

113

Conclusion

Conclusion

In conclusion, surgical correction of deviated nose is considered as one of

the most difficult procedures in rhinoplasty. It can be very frustrating in long term

follow up after an apparent brilliant success immediately postoperative.

Many techniques were described to correct nasal deviation with variable

results without a clear protocol that could enlighten us when each technique has to

be performed in different cases of deviated nose.

According to the results obtained from this study we found that the use of L-

strut cutting and suturing technique, especially in cases with severe septal

deviations, have given good outcomes and proved that it is an effective method to

be used in combination with spreader grafts in treatment of nasal deviation.

114

Summary

Summary

Nasal bones are the most commonly fractured bones in the face, and

fractured nasal bones are a leading cause of an asymmetric nose (Kim and

Toriumi, 2004).

The term “crooked nose” is commonly used for all of the clinical conditions

involving deviation of the nasal pyramid from the midline (Most, 2006).

Injury leading to a crooked nose may be secondary to a recent event or to

years of scarrings and contractions following previous recurrent trauma (Boccieri

and Camillo, 2013).

Still more important than the social aspect of the crooked nose is its

psychological impact on the person. The face plays a crucial role in social

relations. According to this, the position of the nose in the middle of the face

means that any deviation will attract attention. It is therefore people with this type

of deformity usually have complexes and feel insecure (Boccieri and Camillo,

2013).

Surgical correction of a deviated nose is regarded as the most difficult

procedure in rhinoplasty. Deviations can be diverse and complex, therefore an

individualized surgical strategies are needed for each patient (Mendelsohn, 2005).

Numerous techniques were described, involving the use of sections,

incisions and morselization to modify the cartilaginous portion of the dorsal pillar

of the septum (Schlosser et al. 1999).

Extracorporeal septoplasty, spreader grafts and the crossbar grafts are all


also in solving the functional problems (Boccieri and Camillo, 2013).

115

Summary

In the 1980s, Sheen popularized spreader grafts as a method for

reconstruction of the internal nasal valve. Since that time, spreader grafts are

commonly used as volumetric expanders to stabilize and shift the upper lateral

cartilage away from the dorsal septum to increase the internal nasal valve angle.

(Teymoortash et al, 2012)

Furthermore, Byrd et al (1998) described the use of cartilage grafts to

reinforce and to straight the middle third of the nose. The technique extends the use

of traditional spreader grafts from only being used in treatment of nasal valve

stenosis to correction of nasal dorsal deviation.

Using L-strut cutting and suturing with grafting technique was mentioned by

Metzinger et al. (1994). Their study stated that modification of apparent nasal

deviation with L-strut graft had good outcomes without the appearance of any

morbidity or airway obstruction (Ghiasi et al. 2013).

This study about 60 patients underwent an open approach rhinoplasty for the

correction of deformed nose.

Thirty patients were treated with the use of spreader graft technique. We

used the traditional spreader grafts that were attached to the septum by means of

mattress sutures. Bilateral spreader grafts were used to support the septum in

straight position. In all patients, medial and lateral osteotomies were performed

before the placement of the grafts.

The other thirty patients were treated with cutting the dorsal L-strut at a

particular location, and overlapping sutures applied to allow good centralization

and straightening of the crooked nose and increases cephalic rotation of the nasal

tip.

116

Summary

Furthermore, spreader grafts placement in all cases on both sides slightly

extending beyond the anterior septal angle with sometimes insertion of septal

extension graft was done to support the dorsal L-strut and to compensate well for

it’s shortening.

On comparison between both groups regarding visual analogue scale

cosmetic results, we found that the results were not statistically significant (P value

= 0.2). Although that the postoperative visual analogue scale cosmetic results of

good and excellent improvement in group (A) was 78% compared to 66.7% in

group (B).

Also on comparison between both groups regarding the assessment of

preoperative and postoperative photography, we found that the results were not

statistically significant (P value = 0.5). Although that the patients showed good and

excellent improvement were 80% in group (A) compared to 76.7% in group (B).

Although this study was limited by the small number of patients and a

relatively short follow-up period, the surgical outcomes indicated that the dorsal L-

strut cutting and suture technique is an effective method for correcting severe cases

of cephalocaudal convexity of the dorsal L-strut.

117

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الملخص العربي


ان األنف باعتباره جزء ھام من الوجھ فھو یمثل اھمیة كبرى في التعارف االجتماعي، وأي اعوجاج بھ

سوف یكون ظاھرا و ملحوظا أمام كل من یرى وجھ المریض، لذلك معظم مرضى اعوجاج الظھر األنفي

دائما یعانون من أعراض نفسیة و یغلب على سلوكھم ظاھرة العزلة االجتماعیة و قلة الثقة بالنفس.

ان األنف یتكون من جزء عظمي علوي وجزء غضروفي سفلي، وبالتالي فان االعوجاج قد یكون في الجزء

العظمي أو الغضروفي، وبسبب وجود ارتباط شدید بین الجزء العظمي و الجزء الغضروفي فغالبا ما یكون

االعوجاج في االثنین معا.

السبب الرئیسي العوجاج األنف ھو تعرض المریض الصابة في الوجھ اثناء التعرض ألي حادثة تؤدي الى

كسر بعظام األنف أو خروج الحاجز األنفي من مكان اتصالھ بأخدوده العظمي في قاعدة األنف أو االثنین

معا.

ان عملیة استعدال اعوجاج الظھر األنفي خصوصا الجزء الغضروفي منھ من أصعب العملیات التي قد

یواجھھا جراحي تجمیل األنف، ذلك بسبب انھ قد تظھر نتائج جیدة جدا بعد العملیة مباشرة و لكن بعد فترة

لیست بالكبیرة قد یظھر االعوجاج مرة أخرى، و تعزى ھذه المشكلة لوجود قوى خارجیة و أخرى داخلیة

باألنف دائما ما تؤدي الى حالة تسمى بذاكرة الغضروف التي ترفض الوضع الجدید و تعود بالغضروف الى

حالة االعوجاج التي كان علیھا قبل العملیة.

لقد وصفت في تاریخ الطب الحدیث عملیات لیست بالقلیلة و طرق مختلفة تھدف الستعدال االعوجاج

الغضروفي للظھر األنفي، منھا مجرد و ضع رقع غضروفیة أو عظمیة باألنف أو استئصال الحاجز األنفي

بالكامل و استعدالھ خارجیا ثم وضعھ مرة أخرى و تثبیتھ باألنف.

1


في ھذه الدراسة تمت المقارنة بین طریقتین في استعدال االعوجاج الغضروفي للظھر األنفي وھما طریقة

و طریقة الرقعة الفاردة بمفردھا.Lاستخدام الرقعة الفاردة مع قطع و خیاطة دعامة

تمت دراسة النتائج على ستین مریضا مقسمین لمجموعتین متساویتین، ووجد ان النتائج الجیدة والممتازة

في حین انھ L من المرضى الذین تم استخدام طریقة الرقعة الفاردة مع قطع و خیاطة دعامة ٪80وجدت في

فقط، و لكن بمقارنة النتائج ٪76.7وجدت النتائج الجیدة و الممتازة في طریقة الرقعة الفاردة بمفردھا

احصائیا وجدت أنھا ال تشكل فرقا كبیرا.

ھي طریقة Lلقد تم االستنتاج من ھذه الدراسة ان استخدام طریقة الرقعة الفاردة مع قطع وخیاطة دعامة

جیدة و یمكن استخدامھا بشكل موسع لعالج حاالت االعوجاج الغضروفي للظھر األنفي ولم یثبت وجود

مضاعفات مھمة یجب الحذر منھا في ھذه الطریقة.

2

استعدال االعوجاج الغضروفي للظھر االنفي باستخدام طريقة قطع وخياطة Lدعامة

توطئة للحصول على درجة الدكتوراة في األذن و األنف و الحنجرة

مقدمة من الطبيب

أحمد فتحي محمد الدحن

ماجستيرجراحة األذن و األنف و الحنجرة –بكالوريوس الطب و الجراحة

جامعة القاھرة

شرافتحت ا

أسامة محمد عبدالنصير . د.أأستاذ األذن و األنف و الحنجرة كلية الطب

جامعة القاھرة

حسن محمد حسن الحوشي . د.أ أستاذ األذن و األنف و الحنجرة

كلية الطب جامعة القاھرة

أحمد محمد نصار . د مدرس األذن و األنف و الحنجرة

كلية الطب جامعة القاھرة

كلية الطب اھرةجامعة الق

٢٠١٤

prof. dr. usama mohamed abdel naseer prof. dr....

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