The short nose: Preoperative evaluation and management

The short nose: Preoperative evaluation and management

Karim Khalil El-Lamie, MD

Department of Plastic  Surgery, Ain Shams University, Cairo, Egypt. Correspondence:

Assistant  professor in plastic surgery department, Ain Shams University.

Address: 3 Beyrouni  street, H eliopolis, Cairo, Egypt. Phone number: 202 4183038

E.mail:  dr_ karimlamie@}wtmail.com

Abstract

Lengthening the short nose is considered the most difficult operation in rhinoplasty  Several techniques  have been described ranging  from a mere tip graft up to paranasal osteotomies. After preoperative evaluation and measurements, the author suggests a method of lengthening by cartilage grafting using either costal or septal grafts. The type of cartilage grafting depends on the preoperative condition of the nasal septum and the availability of the adequate septal graft. If deemed inappropriate,  a costal cartilage graft is harvested  and shaped to give the desired effect. By applying the technique in 8 patients, adequate lengthening was achieved in 5 cases. The main obstacle to reach the desired length is the inadequate stretchability of the skin envelope especially after a previous trauma or an operation.

Key words: Short nose, lengthening  ofthe nose, rhinoplasty, caudal septal extension graft, costal cartilage graft, septal graft, tongue in groove technique.

Introduction:

The nasal length is a very important determinant in nasal aesthetics. Most surgeons agree    that    direct    clinical    measurement of the nasal length is more useful than anthropometric  one.l  The  normal  nose  has an appropriate  5:3 ratio  between the  length and  height  of  the  nose.2   Lengthening  the short  nose  has  always  been  a dilemma  for the plastic surgeon. Several techniques have been suggested using either septal cartilage grafts  or  costal  cartilage  grafts  to  stretch the  skin  envelope  and  bring  the  tip  into  a more caudal position.3-5  Some authors even recommended extensive osteotomies in order to bring the whole nasal complex into a more caudal  position.6,7    However   no  consensus was   made   about   the  basis   according   to which the surgeon can choose between these

methods and if a costal or septal graft are to be used. Also, how each graft can be sculpted and fixed to provide adequate tip support. According  to  the  preoperative  examination and CT facial scan, the author suggests a predictable method of lengthening the short nose.

Patients and methods:

The  study  was conducted  in Ain Shams

Hospitals from October  2011 to  June 2013,

8 patients were included in the study. The clinical analysis ofthe cause and anatomy of nasal shortening is essential in planning the corrective surgery. The history of previous trauma or surgical intervention if present is taken with every detail possible. Associated nasal  airway  complaints  are  also  included in the history  taking.  The  external  physical

examination consisted of a detailed facial aesthetic analysis with emphasis on the nasal length in relation to the midfacial height and nasal projection. Nasal skin laxity and amount of possible skin and mucous membrane stretch is very important as a tight skin and lining is a limitation in some cases for adequate nasal augmentation. Scars in post-traumatic cases were carefully outlined as well as assessment of  shape  and  position  of  the  nasal  bone, height  of the  nasal  dorsum,  septal  support, tip support and width of nasal base. Internal examination included assessment of septal length and any concomitant deviation.

All 8 cases were subjected to clinical measurement  of  the  actual  and  the  desired nasal length. The actual nasal length was measured from the root of the nose at the level of the superior  palpebral fold with patient's eye fixed on forward  gaze, to the nasal tip. The desired or ideal nasal length is calculated on  the   basis   of  midfacial   height   (MFH) which  is the  distance  from  the  glabella  to the alar base plane.! By multiplying 0.67 the patients  measured  midfacial  height  (MFH), the  proportioned  and ideal  nasal  length for the face can be calculated i.e. Nasal Length=

0.67xMFH.  All patients in the study had an actual nasal length shorter by one em or more than the ideal nasal length.

Options for correction of the short nose is depending  on several  factors: the  condition of nasal septum (available height and length) which is determined by clinical examination and  CT  scan,  the    nasal  skin  and  lining quality and relating it to the desired nasal lengthening and finally concomitant presence of saddle nose deformity. The availability of adequate unmarred septal graft of 2.5x2cm is mandatory if correction using septal extension graft is planned  otherwise  a costal cartilage graft is necessary for the reconstruction. In the latter condition, a 1.5mm K wire is used to fix the costal cartilage graft to the anterior nasal spine in front of the caudal septum. In both types of grafts, the medial and middle crura are then sutured  in the  midline  overlapping the graft leading to distalization of the nose.

Surgical technique:

Using the open  approach,  the  nasal skin is dissected completely to the level of the nasofacial crease horizontally and nasofrontal angle vertically. The periosteum is elevated from the dorsum of nasal bones, lateral and/ or medial osteotomies are performed when indicated.   The  septum   is  dissected   using extra-mucosal tunneling technique and the septal graft is harvested if judged possible leaving an inverted L strut of lcm in width. Otherwise, a 5cm costal cartilage graft is harvested  from  the  5th rib.  To  correct  the foreshortened nose deformity using septal extension  graft, the  latter is shaped  so that it has a longer superior  margin,  usually  by

5mm, than its base. The graft cephalic border is beveled  and overlapped  by around  7mm to the  caudal  margin  of the  caudal  septum using 2 polypropylene  4-0 mattress  sutures. For further  support the  inferior  edge of the graft is sutured to the anterior nasal spine periosteum .Utmost attention is paid to ensure that the caudal margin of the graft sits in the midline Figure(l).  In case of costal cartilage graft a 25mm length xlO mm width and 6mm thick cylinder is carved from the graft and penetrated  by  a  K wire  before  being fixed to  the  anterior  nasal  spine.  The  angulation at which the costal graft is fixed determines the amount of tip distalization. In case of concomitant depressed nasal bridge another graft is sculpted from the costal cartilage and used in onlay fashion  after being penetrated by a K wire to prevent warpage.

The skin is then redraped  and columellar incision   is  temporarily   sutured   to   check adequate   skin  laxity.  If  skin  coverage   is deemed too tight, the septal extension graft is trimmed  sequentially  until adequate  closure is achieved. For the costal cartilage graft, the K wire is bent slightly cephalically to allow approximation   of  the  columellar   incision. Once skin closure is ensured, the columellar suture is removed and the medial and middle crura are  advanced  with the  attached  nasal lining and sutured tongue in groove fashion to the caudal margin ofthe graft. Ifthe lining is deficient, the  mucosa  is further  dissected from the bony septum. If still the lining is tight and  hindering  the  caudal  movement  of  the

alar cartilage, with a double hook on the tip cartilage, a knife is used to release the dorsal aspects  of the  mucoperichondreal  flaps.  Up to three staggered cuts 1em in length and spaced by 1.5cm are made. By staggering the releasing cuts, the cartilaginous septum will always have a mucosal lining on at least one side.

The lower  lateral cartilages  are now sutured to the caudal end of either septal or costal cartilage grafts in a ''tongue in groove" fashion  and  further  tip  refining  sutures  are used for a more pleasing result. In 5 of the 8 patients shield grafts harvested from the ear concha were also added to the tip area for a better tip projection and definition Figure(2).

Results:

8 patients  (6 males  and  2 females)  were included in the study with 5 receiving septal extension grafts and 3 costal cartilage grafts for lengthening aforeshortened nose Table(l).

6  patients  were  of  posttraumatic  etiology,

one patient had a previous rhinoplasty with overzealous  septal  resection  while  1 patient had no history of any previous trauma.  The maximum  lengthening  achieved  was  lOmm and the least was 6mm Figure(3). 5 patients reached the ideal nasal length while 3 patients were short from this goal. The main if not the only the cause for this inadequate lengthening was  the   tightness   of   the   skin   envelope. All  3  patients  had  a  history  of  relatively recent trauma of less than 2 years duration Figure(4). Two of the three patients receiving costal cartilage graft had concomitant saddle nose deformity and received an onlay dorsal graft.   All   patients   were   followed   for   6 months at least and showed no postoperative complication such as infection, abnormal bleeding, nasal airflow obstruction, grafts displacement or extrusion of K wires.

Discussion:

Several causes of short nose are known: congenital, trauma, cocaine addiction, and iatrogenic.8     Lengthening   the   short   nose is   arguably   the   most   difficult   operation in   aesthetic   rhinoplasty.   The   apparently short nose is characterized  by: (1) an obtuse

columellar-labial angle; (2) an overprojecting tip; and (3) a shallow slope (nasofacial angle) or  the  dorsum.2   The  normal  nose  has  an approximately  5:3 ratio  between the  length and height ofthe nose. However since the tip projection is usually altered in the short nose, Byrd et al introduced the midfacial height as way  to  evaluate  the  adequate  nasal  length. Ideally the  nasal  length  is 0.67  that  of  the midfacial height.l In the past using the closed technique, the lengthening was very limited. Without           soft   tissue       release,               lengthening with  cartilage  grafts  was  compromised   by the  stretchability   of  the  tissues.  Moreover much  of  the  gained  length  was  lost in the postoperative  period because the soft tissues (and the contraction  process) simply  pulled the  nose  back  towards  its  original  length sometimes  with  a resultant  deviation.9   The open   rhinoplasty       approach            allowed          for complete   intraoperative   evaluation   of  the condition   beside   complete   and   adequate release of both the mucoperichondriallining as  well  as  skin  envelope.lO Many  authors suggested  different  methods  of lengthening of  the  nose  in  mild  condition   (less  than

0.3cm) such as: release of the alar cartilages from the upper lateral cartilages, composite graft, batten graft, and onlay tip grafts_2,ll, 12

A septal  extension  graft  or costal  cartilage graft was advised for cases between 3-5 mm lengthening.3-5,13 For more lengthening some authors suggested paranasal osteotomies to bring  the  entire  nasal  complex  forward.6,7

The rationale behind this decision is that the lining and skin coverage would not allow for such augmentation.  In this study, all patients included   required   nasal  lengthening   more than  5mm and all  were managed  by either septal   extension   graft   or  costal   cartilage graft.  The  decision  between  both  types  of grafts were based on the condition of septum primarily which was evaluated both clinically and radiologically by CT scan. Many authors suggested  that  for  better  support  a  costal cartilage graft is favored. However according to the results, both grafts offered  equal and stable nasal tip lengthening provided that the septal extension graft is adequately harvested and fixed  to the  caudal  septum.  The  nasal

Figure (1): Intraoperative view showing the septal extension graft after the fixation the actual caudal septum marked by the star. The lower lateral cartilages with the lining mucosa are stretched by the two hooks and fixed to the end ofthe graft by the syringe needle.

Figure (2): (Left) The septal extension graft is overlapped on both sides and sutured in "tongue in groove" fashion to the medial and middle crura of the lower lateral cartilages. (Right) Further tip definition and augmentation can be achieved by onlay shield cartilage graft taken from the ear concha.

Figure (3): (Left) Preoperative side view of  an 18 year old female patient presenting with a post traumatic short nose after a fall on her face at the age of 4 years. (Right) Postoperative view after using a septal cartilage extension  graft and tip concha! cartilage graft. The nasal lengthening achieved was 1Omm.

Figure (4): (Left) Preoperative view of a 17 year old male with history of severe trauma to the nose of 15 months duration and wound repair elsewhere. (Right) Postoperative  view after costal cartilage grafting for both nasal lengthening and for dorsal augmentation. The achieved lengthening was 6 mm, 3 mm shorter than the desired goal.

Table (1): Data of patients.

lining was mainly a problem in the iatrogenic case  but  not   in  the   other  post-traumatic patients. Adequate release of the lining with the   staggered   cuts   allowed   for   adequate stretch  in  all  post-traumatic   cases  without any postoperative   relative             drawbacks. Worst  outcome  was  mainly  seen  in  those who had relatively  recent nasal trauma (less than  2 years) and those who had undergone an  inadequate   rhinoplasty   with   excessive septal  shortening.  The  main  problem  was in the skin  coverage  which  was found  stiff and  incompliant   for   3  patients,   however still  more  than  5mm  lengthening  was  still achievable.  One of the patients followed for more than a year was found to have the skin

becoming   more  resilient  after  that  edema had subsided. Another minor procedure of augmentation can be contemplated later on rather than jumping to a major operation like the paranasal osteotomies from the start.

Conclusion:

Management  of  the  short  nose  requires both very good preoperative planning as well as  mastering   rhinoplasty   skills.  Extensive dissection and release of all nasal components, ability to harvest an adequate septal or costal cartilage  graft,  and  mastering  tip  definition techniques are all prerequisites for attempting such  surgery.  From  the  point  of  view  of strength and tip support, there is no difference