J Oral Maxillofac
Surg
49:133-140.1991
Indications for Simultaneous Orthogna thic and Septorhinoplastic Surgery PETER
D. WAITE,
MPH,
DDS, MD,* AND VICTOR
J. MATUKAS,
DDS, PHD, MDt
Orthognathic and rhinoplastic surgery can be combined successfully when certain guidelines are understood. Relative indications and contraindications have been established that generally yield predictable results. Tip position (rotation and projection) may be the most difficult aspect to predict and, therefore, is best avoided during simultaneous surgery. Major deformities of the dorsum can be easily corrected in conjunction with maxillary surgery. Three cases demonstrating these guidelines are presented and discussed.
tion most susceptible to change during midfacial orthognathic procedures include nasal tip projection, rotation, and alar width. Both tip rotation and tip projection have been shown to be affected by maxillary osteotomies. 3-8 Tip position changes may have an indirect or relative effect on the dorsum, lip, and alar base. Therefore, nasal deformities of tip position (projection and rotation) are less likely indicated for simultaneous rhinoplasty and maxillary surgery. This is because tip position is difficult to precisely predict for each individual patient following maxillary osteotomies.’ Conversely, dorsal abnormalities such as humps, asymmetries, saddle nose deformities, and tip malformations are less affected by maxillary surgery and seem to be better indicated for simultaneous surgery.
Function and esthetics can be blended via simultaneous orthognathic and rhinoplastic surgery to produce a favorable result.’ However, there is the question of when simultaneous surgery should be done and what its implications are. The precise answer to these questions depends on the surgeon’s ability, the degree of deformity, and the patient’s expectations. Because rhinoplasty is more of an art form than orthognathic surgery and is somewhat subjective, it is difficult to provide a clear set of guidelines. Certain relative indications and contraindications can be established; however, the decision to perform rhinoplasty and orthognathic surgery simultaneously should be made on an individual basis by the patient and surgeon. Ideal standards of classic facial proportion and esthetics should be well understood by the surgeon.’ At the same time, the surgeon must recognize potential soft-tissue alterations produced by orthognathic surgery and compensate for these changes in planning. The areas of nasal configura-
Relative Indications for Simultaneous Septorhinoplasty and Orthognathic Surgery FUNCTIONAL NASAL SEPTAL DEVIATIONS
Received from the Department of Oral and Maxillofacial Surgery, School of Dentistry and School of Medicine, University of Alabama at Birmingham. * Associate Professor, Director of Residency Program. t Professor and Chairman. Address correspondence and reprint requests to Dr Waite: Department of Oral and Maxillofacial Surgery, School of Dentistry and School of Medicine, University of Alabama at Birmingham, UAB Station, Birmingham, AL 35294. 0 1991 geons
American
Association
of Oral
and Maxillofacial
Septal deviations with or without significant functional airway obstruction can be corrected simultaneously with Le Fort I maxillary osteotomies. When maxillary impaction is performed, an equal amount of septum is removed to prevent septal deviation or buckling. This can often be done from below, using a “swinging-door” type technique and repositioning the cartilaginous septum in the midline and suturing it to the anterior nasal spine. High septal deviations above the nasomaxillary crest can
Sur-
0276-2391/91/4902-0006$3.00/O
133
134
RHINOPLASTY
also be corrected silization.
by submucosal
resection
or mor-
MINOR DEFECTSOF TIP AND/ORALAR BASE MORPHOLOGY
Defects of tip morphology, such as in the amorphous nose and the bulbous tip, can be corrected simultaneously because maxillary surgery will not alter tip form (case I). The form of the nasal tip is produced by the configuration of the lateral cura, medial cura, and septum. It is also influenced by the relationship of the upper lateral cartilages and superior septal angle to these cartilages. Alterations of the lower lateral cartilages will help produce definition of the tip and can allow for minor changes in tip position. Excision of the cephalic edge of the lateral cura in a complete strip will help define the tip and allow slight cephalic tip rotation. Rhinoplastic procedures designed to alter tip position (rotation and projection) can be performed simultaneously only in situations where the position of the anterior maxilla will not be altered. Examples would be an anterior open bite deformity treated by posterior maxillary impaction and a maxillary transverse deficiency treated by posterior maxillary expansion. Vertical maxillary excess is often associated with slitlike nares. Vertical maxillary impaction anteriorly may produce alar base widening and open the nasal valve, with improved nasal breathing. Minor superior tip rotation with alar base flaring is known to occur with total maxillary impaction and is often a desirable esthetic change unless a saddle nose deformity exists, in which case the nasal deformity will be exaggerated. On the other hand, superior tip rotation may create the illusion of less apparent dorsal prominence; however, it will seldom eliminate an obviously prominent dorsum. In some cases, less dorsal reduction may be needed when cephalic tip rotation occurs. MAJOR NASAL ABNORMALITIES ESPECIALLYDORSUM
Small changes in anterior maxillary position (~4 mm) will have a minimal effect on nasal tip position (rotation and projection). Large changes in anterior maxillary position (>4 mm) may result in more obvious nasal changes by altering tip position and the overall relationship of the dorsum and tip. These changes can be predicted based on general trends.3-8 Maxillary advancement and maxillary impaction will increase tip projection and cephalic rotation. When these minor changes will not correct or normalize the nose, rhinoplastic procedures should be employed. An example is vertical maxil-
AND SIMULTANEOUS
ORTHOGNATHIC
SURGERY
lary excess with a prominent dorsal deformity (case 2). If the dorsal prominence is not too large, it may become less apparent if the nasal tip is projected and rotated cephalically as a result of maxillary impaction. The reduced dorsal prominence is an illusion and is indirectly related to the new tip position. It is also possible that maxillary movements may worsen the appearance of a nasal deformity. For example, a saddle nose deformity may be made worse in cases using maxillary impaction or advancement (case 3). In such cases, increasing cephalic tip rotation or projection will increase the dorsal deficiency. A severe dorsal deformity will generally remain after maxillary impaction, or advancement in spite of mild cephalic tip rotation. Maxillary surgery may slightly alter the nasal configuration by changing tip position, but it will never correct a large dorsal deformity. Thus, the relationship between the nasal dorsum and tip should be known and compensated for during simultaneous septorhinoplastic and orthognathic surgery. Relative Contraindications MINOR
CORRECTIONOF TIP POSITION (IE, TIP
ROTATION AND PROJECTION) Fine detail and exact tip position are difficult to predict for each individual even in rhinoplasty as an isolated procedure. General trends for changes in tip position with orthognathic surgery can be determined, but precise prediction is not reliable.’ Tip position (projection and rotation) must be distinguished from tip morphology. There are many variables that affect apparent tip position. Soft-tissue procedures on the lip, edema, and bony changes beneath the alar base will alter support of the tip.” Changing the support of the tripod components, ie, medial and lateral cura, also ultimately change tip position (tip rotation, tip projection).” Treatment planning for overprojected, over-rotated, and ptotic nasal tips is difficult when the maxillary movements alter the nasal base. DETAILED CORRECTIONOF MINOR NASAL DEFORMITIES Because precise prediction of tip position may not be possible following maxillary surgery, detailed corrections of minor deformities should not be attempted. For example, a slightly ptotic tip with an otherwise normal nose is difficult to correct simultaneously with anterior maxillary changes. Nasal deformities that are only slightly beyond normal or defects noticed only by the patient or discovered by critical analysis are best treated by a delayed
135
WAITE AND MATUKAS
primary rhinoplasty. Delayed rhinoplasty allows more accurate changes in nasal configuration and facial harmony. Report of Cases Case 1 D.L. is a 27-year-old woman with apertognathia, vertical maxillary excess, and mandibular retrognathia. She has a narrow alar base and a bulbous, boxy nasal tip. Preoperative lip length was 15 mm, alar width was 29 mm, the nasolabial angle was 85”, and she showed 15 mm of tooth and gingiva when smiling (Figs 1 to 3). A surgical treatment plan was first established based on the ideal position of the maxilla. A three-piece Le Fort I maxillary osteotomy with bilateral mandibular sagittal split ramus osteotomies was planned. Presurgical prediction was for the maxilla to be impacted 3 mm in the anterior maxilla and 6 mm posteriorly. Surgically, the maxilla was repositioned and the mandible was placed into a surgical splint and rigidly fixed with three bicortical screws bilaterally. The lip was closed in a standard fashion without a V-Y mucosal plasty or alar base cinch. The vestibular incision was closed so that the alar base would widen. Facial muscles were not reapproximated in the midline. The septum was sutured to the anterior nasal spine to prevent displacement or deviation. Alar base widening and cephalic tip rotation were expected to result from the maxillary impaction. These expectations were included in the rhinoplasty treatment plan. The boxy tip resulted from strong prominent alar cartilages blending with the upper lateral cartilages and preventing tip detinition. Maxillary impaction does not alter or improve the configuration of the nasal tip or detine it from the remaining anatomy of the nose. Therefore, conservative internal tip rhinoplasty was performed. An incomplete transfixion incision, and intercartilaginous and marginal incisions were created. The cartilages were delivered and a complete strip excision was done, preserving 4 to 5 mm of the lateral crus. Three millimeters of caudal septum was reduced to allow tip rotation and raise the superior septal angle. Postoperatively, the nasolabial angle was increased and the lip-to-tip ratio was one to one. This demonstrated that the nasal tip had rotated cephalically. Tip projection had slightly decreased and lip length had not changed, but the position of subnasale had been elevated (Fig 4). Alar base widening and compensatory decrease in tip projection are favorable for this case (Fig 5). The alar cartilage delivery and complete strip excision narrowed the tip of the nose as seen in the basal view (Fig 6). Case 2 A.M. is a 24-year-old woman with vertical maxillary excess, mandibular retrognathia, microgenia, a nasal septal deviation, and a dorsal cartilaginous and bony hump deformity (Figs 7 and 8). These deformities were developmental in origin. A Le Fort I maxillary osteotomy, with 2 mm horizontal impaction and 4 mm advancement, was planned for the patient. The buccal fat pads were to be removed bilaterally in an attempt to accentuate the zygoma region and decrease the roundness of the face. The mandible was to be advanced into the proper predetermined occlusion with concomitant advancement genioplasty.
It was anticipated that maxillary advancement would increase tip projection and cephalic tip rotation, which might lessen the appearance of the dorsal prominence, but dorsal reduction was still indicated. Therefore, the rhinoplasty treatment plan could require conservative modification after the effects of orthognathic surgery are evaluated. Figure 9 demonstrates the decreased dorsal prominence as the nasal base and tip were cephalically rotated and projected as a result of the maxillary surgery. The change in subnasale and the anterior nasal spine also produced a more prominent columella. An internal rhinoplasty was performed after the endotracheal tube was changed to the oral route. An incomplete transfixion incision, and intercartilaginous and marginal incisions were made. A inferior septoplasty was performed after the Le Fort I down fracture and the septum was stabilized to the anterior nasal spine with 2-O suture. The dorsoseptal rhinoplasty was completed next. The dorsal hump was reduced with a no. 11 scalpel and a Rubin osteotome. Lateral osteotomies were made with a Nievert osteotome. The lower lateral cartilages were exposed and delivered, and a conservative complete strip excision was performed. Three millimeters of caudal septum was excised to allow for rotation and to correct the excessive columella. The septal mucosa was closed with a running transseptal chromic suture. Other mucosal incisions were closed with interrupted chromic sutures. The nose was slightly packed with a hemostatic dressing. Routine taping and external splinting were performed. Postoperative photographs showed a significant improvement in facial esthetics. Minor rhinoplastic procedures were performed, but when combined with the beneficial changes of orthognathic surgery, a major facial improvement was noted (Figs 10 and 11). Case 3 P.T. is a 44-year-old woman with a developmental deformity involving maxillary deficiency, mandibular laterognathia, prognathia, and a saddle nose deformity (Figs 12 and 13). A Le Fort I maxillary osteotomy with advancement and slight rotation was planned. The anterior maxilla would be moved 3 mm down and 5 mm forward. Maxillary advancement would increase tip projection and cephalic rotation, but the anterior maxillary downgraft could counter the effect of cephalic tip rotation. Increased tip projection and cephalic tip rotation will worsen the apparent saddle nose deformity. The posterior maxilla was impacted 3 mm. The maxilla was rigidly fixed with four titanium miniplates and the mandible was set back into the splint after a bilateral sagittal ramus osteotomy. The mandible was rigidly fixed bilaterally with three bicortical titanium screws. The lip was not closed in a V-Y fashion, but the levator labii superioris and nasalis muscles and septum were closed toward the anterior nasal spine with a 2-O suture. The patient refused banked cartilage; therefore, a large piece of rib cartilage was obtained through an inframammary incision, carved, and positioned over the dorsum through an intercartilaginous and transfixion incision and stabilized to the skin with Prolene sutures. A standard rhinoplasty dressing was applied. Figures 14 and 15 show the postoperative result.
Discussion The benefit of rhinoplasty has been recognized orthognathic treatment planning. The purpose
in of
136
RHINOPLASTY
FIGURE 1.
Case 1, Preoperative
lateral profile.
FIGURE 2.
Case I, Preoperative
frontal profile.
FIGURE 3. Case 1, Preoperative basal view of nose demonstrating the boxy, bulbous tip caused by the strong lower lateral cartilages.
AND SIMULTANEOUS
ORTHOGNATHIC
SURGERY
FIGURE 4.
Case 1, Lateral profile 24 months postoperatively.
FIGURE 5.
Case I, Frontal profile 24 months postoperatively.
FIGURE 6.
Case 1. Basal view 24 months postoperatively.
137
WAITE AND MATUKAS
FIGURE 7.
Cuse 2. Preoperative
lateral profile.
FIGURE 10.
Case 2. l&month postoperative
lateral profile.
FIGURE 8.
Case 2, Preoperative
frontal protile.
FIGURE 11.
Case 2, 12-month postoperative
frontal profile.
FIGURE 9. Case 2, Immediate postorthognathic. but prerhinoplastic surgery view, demonstrating slight rotation of tip and apparent illusionary decrease in dorsal hump. Subnasale and columella are increased by maxillary advancement of anterior nasal spine.
138
RHINOPLASTY
FIGURE 12.
Case 3, Preoperative
lateral profile.
this article was to identify the indications that benefit by simultaneous septorhinoplasty and orthognathic surgery, and to demonstrate examples of cases in which these indications were applied. In this regard, the surgeon should take advantage of the predicted favorable nasal changes that occur
FIGURE 13. Case 3, Preoperative laterognathism.
AND SIMULTANEOUS
ORTHOGNATHIC
SURGERY
FIGURE 14. Case 3, 12-month postoperative lateral profile, following maxillary advancement, mandibular setback and autologous cartilage rib graft to nasal dorsum.
with maxillary surgery and learn to correct or prevent the unfavorable ones. Simultaneous surgery is most often indicated for severe deformities of the dorsum and minor nasal deformities of tip morphology or definition. Such dorsal deformities can be predictably improved or
frontal view demonstrating FIGURE 15.
Case 3, 1Zmonth postoperative
frontal view.
139
WAITE AND MATUKAS
normalized, but the possibility of subsequent revision should be explained to the patient. Revision rhinoplasty after simultaneous cases should not be viewed as failure because primary rhinoplasty frequently needs further modification. Both large dorsal humps and broad noses can be corrected accurately and in conjunction with maxillary osteotomies. This is because the maxillary change does not alter these aspects of the nose. Minor dorsal humps are more difficult to treat simultaneously because the margin of error is small and the relationship of the tip to dorsum is critical. Minor nasal deformities should be considered for delayed rhinoplasty unless the surgeon is experienced and confident about predicted nasal tip changes resulting from maxillary surgery. Minor abnormalities of the nasal dorsum with poor tip position (as opposed to abnormal tip morphology) should be reduced with caution because the final relationship of the dorsum, nasal tip, and lip is extremely variable in cases of simultaneous surgery and difficult to predict. This relationship involves the nasolabial angle and is greatly influenced by the Le Fort I maxillary osteotomy and the vestibular incision. Careful management of the nasal cartilaginous septum, anterior nasal spine, and soft tissue of the lip is required to avoid unnatural changes in the relationship of the nose, tip, and nasolabial angle. lo Inadequate reduction of the cartilaginous nasal dorsum and modification of the nasal base and columella either by the Le Fort osteotomy or complete transfixion incision may result in a polly-beak deformity. lo.” Poor tip support is a common cause of a polly-beak deformity in isolated rhinoplasty and is perhaps a more complicated problem when combined with maxillary surgery because of added variables. A polly-beak deformity occurs when the tip settles and the supratip break is lost. The surgeon should take every precaution to maintain tip position (projection and rotation) and avoid maneuvers that compromise its support. The nasal tip is supported by fixation ligaments to the upper lateral cartilages at the scroll and by ligaments of the medial cura to the caudal septum.12 Excessive dissection of the caudal septum through the Le Fort incision may disrupt the fixation of the medial cura-septal caudal overlap. This, as well as a complete transfixion incision, can result in loss of medial cura tip support and ptosis. Settling of the tip is expected to occur in both isolated and simultaneous rhinoplasty and, therefore, should be anticipated in treatment planning. In addition, the V-Y closure of the lip may not be predictable or permanent. When the maxilla is impacted or advanced in conjunction with procedures
such as alar base cinching and V-Y closure, excessive cephalic tip rotation and increased projection occur. This will give the initial appearance of adequate supra-tip break and indicate less need for dorsal cartilage reduction. As the tip settles and the V-Y closure in the lip resolves, however, the supratip break becomes diminished and the presence of a polly-beak or ptotic tip may be apparent. Similarly, the soft-tissue response of the lip and tip is extremely variable in maxillary procedures and it does effect the nasolabial angle. Problems certainly can occur in severe deformities, but the margin of error is greater and the final result more acceptable. Therefore, a large dorsal deformity and poor tip definition are the best indications for simultaneous surgery. Minor variations in nasal morphology can prevent a normal-sized nose from looking elegant and harmonious. Poor tip definition, eg, an amorphous tip, often is manifested by tip bulbosity, thick skin, strong resilient lower lateral cartilages, tip ptosis, and sometimes alterations in projection and rotation. The cosmetic benefit of orthognathic surgery frequently produces only subtle changes in alar base width, or tip position, but greatly contributes to an overall change. When these alterations are unfavorable, appropriate surgical intervention may be simultaneously undertaken to either compensate or modify the nasomaxillary complex. Maxillary impaction in patients with a wide alar base may result in exacerbation of nasal form unless alar base cinching, Weir resection, or tip modification is performed. Conversely, patients with a narrow alar base, prominent lower lateral cartilages. and a ptotic tip undergoing maxillary impaction will greatly benefit from minor rhinoplasty techniques performed in conjunction with the orthognathic surgery. In such cases, it is important to be conservative and inform the patient of the potential benefits and alterations from such surgery. Simultaneous orthognathic and rhinoplastic procedures can be predictably performed with good results when the proper indications are identified. It is essential to have a thorough understanding of both rhinoplasty and orthognathic techniques. The combination of these procedures can benefit or complicate the situation depending on how they are performed. Common sense, precise planning, and accurate surgery will often result in a complimentary improvement of function and esthetics. References 1. Waite P, Matukas V, Sawer D: Simultaneous rhinoplasty procedures in orthognathic surgery. Int J Oral Maxillofac Surg 17:298, 1988
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RHINOPLASTY
2. Powell N, Humphreys B: Proportions of the Aesthetic Face. New York. NY. Theime-Stratton, 1984. D 59 3. Dann JJ, Fonseca ‘RJ, Bell WH: Soft tissue-changes associated with total maxillary advancement: A preliminary study. J Oral Surg 34: 19, 1976 4. Freihofer HP: The lip profile after correction of retromaxillism in cleft and non-cleft patients. J Maxillofac Surg 14:301, 1986 5. Radney LJ, Jacobs JD: Soft tissue changes associated with surgical total maxillary intrusion. Am J Orthod 80:191, 1981 6. Carlotti AE, Aschaffensburg PH, Schendel SA: Facial changes associated with surgical advancement of the lip and maxilla. J Oral Maxillofac Surg 44593, 1986 7. Stella JP, Streater MR, Epker BN, et al: Predictability of upper lip soft tissue changes with maxillary advancement. J Oral Maxillofac Surg 47:697, 1989
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ORTHOGNATHIC
SURGERY
8. Schendel SA, Williamson LW: Surgical maxillary superior repositioning and the facial muscles. J Oral Surg 41:235, 1983 9. Gassmann CJ, Nishioka GJ, Van Sickels JE, et al: A lateral cephalometric analysis of nasal morphologh following Le Fort I osteotomy applying photometric analysis techniques. J Oral Maxillofac Surg 47:926, 1989 10. Webster RC: Advances in surgery of the tip intact rim cartilage techniques and the tip-columella-lip esthetic complex, symposium of corrective rhinoplasty. Otolaryngol Clin North Am 8:615, 1975 11. McCollough EG, Mangat D: Systematic approach to correction of the nasal tip in rhinoplasty. Arch Otolaryngol 107:12, 1981 12. Anderson JR, Ries WR: Rhinoplasty: Emphasizing the External Approach. New York, NY, Thieme, 1986, pp 65-72
Surg
49:133-140.1991
Indications for Simultaneous Orthogna thic and Septorhinoplastic Surgery PETER
D. WAITE,
MPH,
DDS, MD,* AND VICTOR
J. MATUKAS,
DDS, PHD, MDt
Orthognathic and rhinoplastic surgery can be combined successfully when certain guidelines are understood. Relative indications and contraindications have been established that generally yield predictable results. Tip position (rotation and projection) may be the most difficult aspect to predict and, therefore, is best avoided during simultaneous surgery. Major deformities of the dorsum can be easily corrected in conjunction with maxillary surgery. Three cases demonstrating these guidelines are presented and discussed.
tion most susceptible to change during midfacial orthognathic procedures include nasal tip projection, rotation, and alar width. Both tip rotation and tip projection have been shown to be affected by maxillary osteotomies. 3-8 Tip position changes may have an indirect or relative effect on the dorsum, lip, and alar base. Therefore, nasal deformities of tip position (projection and rotation) are less likely indicated for simultaneous rhinoplasty and maxillary surgery. This is because tip position is difficult to precisely predict for each individual patient following maxillary osteotomies.’ Conversely, dorsal abnormalities such as humps, asymmetries, saddle nose deformities, and tip malformations are less affected by maxillary surgery and seem to be better indicated for simultaneous surgery.
Function and esthetics can be blended via simultaneous orthognathic and rhinoplastic surgery to produce a favorable result.’ However, there is the question of when simultaneous surgery should be done and what its implications are. The precise answer to these questions depends on the surgeon’s ability, the degree of deformity, and the patient’s expectations. Because rhinoplasty is more of an art form than orthognathic surgery and is somewhat subjective, it is difficult to provide a clear set of guidelines. Certain relative indications and contraindications can be established; however, the decision to perform rhinoplasty and orthognathic surgery simultaneously should be made on an individual basis by the patient and surgeon. Ideal standards of classic facial proportion and esthetics should be well understood by the surgeon.’ At the same time, the surgeon must recognize potential soft-tissue alterations produced by orthognathic surgery and compensate for these changes in planning. The areas of nasal configura-
Relative Indications for Simultaneous Septorhinoplasty and Orthognathic Surgery FUNCTIONAL NASAL SEPTAL DEVIATIONS
Received from the Department of Oral and Maxillofacial Surgery, School of Dentistry and School of Medicine, University of Alabama at Birmingham. * Associate Professor, Director of Residency Program. t Professor and Chairman. Address correspondence and reprint requests to Dr Waite: Department of Oral and Maxillofacial Surgery, School of Dentistry and School of Medicine, University of Alabama at Birmingham, UAB Station, Birmingham, AL 35294. 0 1991 geons
American
Association
of Oral
and Maxillofacial
Septal deviations with or without significant functional airway obstruction can be corrected simultaneously with Le Fort I maxillary osteotomies. When maxillary impaction is performed, an equal amount of septum is removed to prevent septal deviation or buckling. This can often be done from below, using a “swinging-door” type technique and repositioning the cartilaginous septum in the midline and suturing it to the anterior nasal spine. High septal deviations above the nasomaxillary crest can
Sur-
0276-2391/91/4902-0006$3.00/O
133
134
RHINOPLASTY
also be corrected silization.
by submucosal
resection
or mor-
MINOR DEFECTSOF TIP AND/ORALAR BASE MORPHOLOGY
Defects of tip morphology, such as in the amorphous nose and the bulbous tip, can be corrected simultaneously because maxillary surgery will not alter tip form (case I). The form of the nasal tip is produced by the configuration of the lateral cura, medial cura, and septum. It is also influenced by the relationship of the upper lateral cartilages and superior septal angle to these cartilages. Alterations of the lower lateral cartilages will help produce definition of the tip and can allow for minor changes in tip position. Excision of the cephalic edge of the lateral cura in a complete strip will help define the tip and allow slight cephalic tip rotation. Rhinoplastic procedures designed to alter tip position (rotation and projection) can be performed simultaneously only in situations where the position of the anterior maxilla will not be altered. Examples would be an anterior open bite deformity treated by posterior maxillary impaction and a maxillary transverse deficiency treated by posterior maxillary expansion. Vertical maxillary excess is often associated with slitlike nares. Vertical maxillary impaction anteriorly may produce alar base widening and open the nasal valve, with improved nasal breathing. Minor superior tip rotation with alar base flaring is known to occur with total maxillary impaction and is often a desirable esthetic change unless a saddle nose deformity exists, in which case the nasal deformity will be exaggerated. On the other hand, superior tip rotation may create the illusion of less apparent dorsal prominence; however, it will seldom eliminate an obviously prominent dorsum. In some cases, less dorsal reduction may be needed when cephalic tip rotation occurs. MAJOR NASAL ABNORMALITIES ESPECIALLYDORSUM
Small changes in anterior maxillary position (~4 mm) will have a minimal effect on nasal tip position (rotation and projection). Large changes in anterior maxillary position (>4 mm) may result in more obvious nasal changes by altering tip position and the overall relationship of the dorsum and tip. These changes can be predicted based on general trends.3-8 Maxillary advancement and maxillary impaction will increase tip projection and cephalic rotation. When these minor changes will not correct or normalize the nose, rhinoplastic procedures should be employed. An example is vertical maxil-
AND SIMULTANEOUS
ORTHOGNATHIC
SURGERY
lary excess with a prominent dorsal deformity (case 2). If the dorsal prominence is not too large, it may become less apparent if the nasal tip is projected and rotated cephalically as a result of maxillary impaction. The reduced dorsal prominence is an illusion and is indirectly related to the new tip position. It is also possible that maxillary movements may worsen the appearance of a nasal deformity. For example, a saddle nose deformity may be made worse in cases using maxillary impaction or advancement (case 3). In such cases, increasing cephalic tip rotation or projection will increase the dorsal deficiency. A severe dorsal deformity will generally remain after maxillary impaction, or advancement in spite of mild cephalic tip rotation. Maxillary surgery may slightly alter the nasal configuration by changing tip position, but it will never correct a large dorsal deformity. Thus, the relationship between the nasal dorsum and tip should be known and compensated for during simultaneous septorhinoplastic and orthognathic surgery. Relative Contraindications MINOR
CORRECTIONOF TIP POSITION (IE, TIP
ROTATION AND PROJECTION) Fine detail and exact tip position are difficult to predict for each individual even in rhinoplasty as an isolated procedure. General trends for changes in tip position with orthognathic surgery can be determined, but precise prediction is not reliable.’ Tip position (projection and rotation) must be distinguished from tip morphology. There are many variables that affect apparent tip position. Soft-tissue procedures on the lip, edema, and bony changes beneath the alar base will alter support of the tip.” Changing the support of the tripod components, ie, medial and lateral cura, also ultimately change tip position (tip rotation, tip projection).” Treatment planning for overprojected, over-rotated, and ptotic nasal tips is difficult when the maxillary movements alter the nasal base. DETAILED CORRECTIONOF MINOR NASAL DEFORMITIES Because precise prediction of tip position may not be possible following maxillary surgery, detailed corrections of minor deformities should not be attempted. For example, a slightly ptotic tip with an otherwise normal nose is difficult to correct simultaneously with anterior maxillary changes. Nasal deformities that are only slightly beyond normal or defects noticed only by the patient or discovered by critical analysis are best treated by a delayed
135
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primary rhinoplasty. Delayed rhinoplasty allows more accurate changes in nasal configuration and facial harmony. Report of Cases Case 1 D.L. is a 27-year-old woman with apertognathia, vertical maxillary excess, and mandibular retrognathia. She has a narrow alar base and a bulbous, boxy nasal tip. Preoperative lip length was 15 mm, alar width was 29 mm, the nasolabial angle was 85”, and she showed 15 mm of tooth and gingiva when smiling (Figs 1 to 3). A surgical treatment plan was first established based on the ideal position of the maxilla. A three-piece Le Fort I maxillary osteotomy with bilateral mandibular sagittal split ramus osteotomies was planned. Presurgical prediction was for the maxilla to be impacted 3 mm in the anterior maxilla and 6 mm posteriorly. Surgically, the maxilla was repositioned and the mandible was placed into a surgical splint and rigidly fixed with three bicortical screws bilaterally. The lip was closed in a standard fashion without a V-Y mucosal plasty or alar base cinch. The vestibular incision was closed so that the alar base would widen. Facial muscles were not reapproximated in the midline. The septum was sutured to the anterior nasal spine to prevent displacement or deviation. Alar base widening and cephalic tip rotation were expected to result from the maxillary impaction. These expectations were included in the rhinoplasty treatment plan. The boxy tip resulted from strong prominent alar cartilages blending with the upper lateral cartilages and preventing tip detinition. Maxillary impaction does not alter or improve the configuration of the nasal tip or detine it from the remaining anatomy of the nose. Therefore, conservative internal tip rhinoplasty was performed. An incomplete transfixion incision, and intercartilaginous and marginal incisions were created. The cartilages were delivered and a complete strip excision was done, preserving 4 to 5 mm of the lateral crus. Three millimeters of caudal septum was reduced to allow tip rotation and raise the superior septal angle. Postoperatively, the nasolabial angle was increased and the lip-to-tip ratio was one to one. This demonstrated that the nasal tip had rotated cephalically. Tip projection had slightly decreased and lip length had not changed, but the position of subnasale had been elevated (Fig 4). Alar base widening and compensatory decrease in tip projection are favorable for this case (Fig 5). The alar cartilage delivery and complete strip excision narrowed the tip of the nose as seen in the basal view (Fig 6). Case 2 A.M. is a 24-year-old woman with vertical maxillary excess, mandibular retrognathia, microgenia, a nasal septal deviation, and a dorsal cartilaginous and bony hump deformity (Figs 7 and 8). These deformities were developmental in origin. A Le Fort I maxillary osteotomy, with 2 mm horizontal impaction and 4 mm advancement, was planned for the patient. The buccal fat pads were to be removed bilaterally in an attempt to accentuate the zygoma region and decrease the roundness of the face. The mandible was to be advanced into the proper predetermined occlusion with concomitant advancement genioplasty.
It was anticipated that maxillary advancement would increase tip projection and cephalic tip rotation, which might lessen the appearance of the dorsal prominence, but dorsal reduction was still indicated. Therefore, the rhinoplasty treatment plan could require conservative modification after the effects of orthognathic surgery are evaluated. Figure 9 demonstrates the decreased dorsal prominence as the nasal base and tip were cephalically rotated and projected as a result of the maxillary surgery. The change in subnasale and the anterior nasal spine also produced a more prominent columella. An internal rhinoplasty was performed after the endotracheal tube was changed to the oral route. An incomplete transfixion incision, and intercartilaginous and marginal incisions were made. A inferior septoplasty was performed after the Le Fort I down fracture and the septum was stabilized to the anterior nasal spine with 2-O suture. The dorsoseptal rhinoplasty was completed next. The dorsal hump was reduced with a no. 11 scalpel and a Rubin osteotome. Lateral osteotomies were made with a Nievert osteotome. The lower lateral cartilages were exposed and delivered, and a conservative complete strip excision was performed. Three millimeters of caudal septum was excised to allow for rotation and to correct the excessive columella. The septal mucosa was closed with a running transseptal chromic suture. Other mucosal incisions were closed with interrupted chromic sutures. The nose was slightly packed with a hemostatic dressing. Routine taping and external splinting were performed. Postoperative photographs showed a significant improvement in facial esthetics. Minor rhinoplastic procedures were performed, but when combined with the beneficial changes of orthognathic surgery, a major facial improvement was noted (Figs 10 and 11). Case 3 P.T. is a 44-year-old woman with a developmental deformity involving maxillary deficiency, mandibular laterognathia, prognathia, and a saddle nose deformity (Figs 12 and 13). A Le Fort I maxillary osteotomy with advancement and slight rotation was planned. The anterior maxilla would be moved 3 mm down and 5 mm forward. Maxillary advancement would increase tip projection and cephalic rotation, but the anterior maxillary downgraft could counter the effect of cephalic tip rotation. Increased tip projection and cephalic tip rotation will worsen the apparent saddle nose deformity. The posterior maxilla was impacted 3 mm. The maxilla was rigidly fixed with four titanium miniplates and the mandible was set back into the splint after a bilateral sagittal ramus osteotomy. The mandible was rigidly fixed bilaterally with three bicortical titanium screws. The lip was not closed in a V-Y fashion, but the levator labii superioris and nasalis muscles and septum were closed toward the anterior nasal spine with a 2-O suture. The patient refused banked cartilage; therefore, a large piece of rib cartilage was obtained through an inframammary incision, carved, and positioned over the dorsum through an intercartilaginous and transfixion incision and stabilized to the skin with Prolene sutures. A standard rhinoplasty dressing was applied. Figures 14 and 15 show the postoperative result.
Discussion The benefit of rhinoplasty has been recognized orthognathic treatment planning. The purpose
in of
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FIGURE 1.
Case 1, Preoperative
lateral profile.
FIGURE 2.
Case I, Preoperative
frontal profile.
FIGURE 3. Case 1, Preoperative basal view of nose demonstrating the boxy, bulbous tip caused by the strong lower lateral cartilages.
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FIGURE 4.
Case 1, Lateral profile 24 months postoperatively.
FIGURE 5.
Case I, Frontal profile 24 months postoperatively.
FIGURE 6.
Case 1. Basal view 24 months postoperatively.
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FIGURE 7.
Cuse 2. Preoperative
lateral profile.
FIGURE 10.
Case 2. l&month postoperative
lateral profile.
FIGURE 8.
Case 2, Preoperative
frontal protile.
FIGURE 11.
Case 2, 12-month postoperative
frontal profile.
FIGURE 9. Case 2, Immediate postorthognathic. but prerhinoplastic surgery view, demonstrating slight rotation of tip and apparent illusionary decrease in dorsal hump. Subnasale and columella are increased by maxillary advancement of anterior nasal spine.
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FIGURE 12.
Case 3, Preoperative
lateral profile.
this article was to identify the indications that benefit by simultaneous septorhinoplasty and orthognathic surgery, and to demonstrate examples of cases in which these indications were applied. In this regard, the surgeon should take advantage of the predicted favorable nasal changes that occur
FIGURE 13. Case 3, Preoperative laterognathism.
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FIGURE 14. Case 3, 12-month postoperative lateral profile, following maxillary advancement, mandibular setback and autologous cartilage rib graft to nasal dorsum.
with maxillary surgery and learn to correct or prevent the unfavorable ones. Simultaneous surgery is most often indicated for severe deformities of the dorsum and minor nasal deformities of tip morphology or definition. Such dorsal deformities can be predictably improved or
frontal view demonstrating FIGURE 15.
Case 3, 1Zmonth postoperative
frontal view.
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normalized, but the possibility of subsequent revision should be explained to the patient. Revision rhinoplasty after simultaneous cases should not be viewed as failure because primary rhinoplasty frequently needs further modification. Both large dorsal humps and broad noses can be corrected accurately and in conjunction with maxillary osteotomies. This is because the maxillary change does not alter these aspects of the nose. Minor dorsal humps are more difficult to treat simultaneously because the margin of error is small and the relationship of the tip to dorsum is critical. Minor nasal deformities should be considered for delayed rhinoplasty unless the surgeon is experienced and confident about predicted nasal tip changes resulting from maxillary surgery. Minor abnormalities of the nasal dorsum with poor tip position (as opposed to abnormal tip morphology) should be reduced with caution because the final relationship of the dorsum, nasal tip, and lip is extremely variable in cases of simultaneous surgery and difficult to predict. This relationship involves the nasolabial angle and is greatly influenced by the Le Fort I maxillary osteotomy and the vestibular incision. Careful management of the nasal cartilaginous septum, anterior nasal spine, and soft tissue of the lip is required to avoid unnatural changes in the relationship of the nose, tip, and nasolabial angle. lo Inadequate reduction of the cartilaginous nasal dorsum and modification of the nasal base and columella either by the Le Fort osteotomy or complete transfixion incision may result in a polly-beak deformity. lo.” Poor tip support is a common cause of a polly-beak deformity in isolated rhinoplasty and is perhaps a more complicated problem when combined with maxillary surgery because of added variables. A polly-beak deformity occurs when the tip settles and the supratip break is lost. The surgeon should take every precaution to maintain tip position (projection and rotation) and avoid maneuvers that compromise its support. The nasal tip is supported by fixation ligaments to the upper lateral cartilages at the scroll and by ligaments of the medial cura to the caudal septum.12 Excessive dissection of the caudal septum through the Le Fort incision may disrupt the fixation of the medial cura-septal caudal overlap. This, as well as a complete transfixion incision, can result in loss of medial cura tip support and ptosis. Settling of the tip is expected to occur in both isolated and simultaneous rhinoplasty and, therefore, should be anticipated in treatment planning. In addition, the V-Y closure of the lip may not be predictable or permanent. When the maxilla is impacted or advanced in conjunction with procedures
such as alar base cinching and V-Y closure, excessive cephalic tip rotation and increased projection occur. This will give the initial appearance of adequate supra-tip break and indicate less need for dorsal cartilage reduction. As the tip settles and the V-Y closure in the lip resolves, however, the supratip break becomes diminished and the presence of a polly-beak or ptotic tip may be apparent. Similarly, the soft-tissue response of the lip and tip is extremely variable in maxillary procedures and it does effect the nasolabial angle. Problems certainly can occur in severe deformities, but the margin of error is greater and the final result more acceptable. Therefore, a large dorsal deformity and poor tip definition are the best indications for simultaneous surgery. Minor variations in nasal morphology can prevent a normal-sized nose from looking elegant and harmonious. Poor tip definition, eg, an amorphous tip, often is manifested by tip bulbosity, thick skin, strong resilient lower lateral cartilages, tip ptosis, and sometimes alterations in projection and rotation. The cosmetic benefit of orthognathic surgery frequently produces only subtle changes in alar base width, or tip position, but greatly contributes to an overall change. When these alterations are unfavorable, appropriate surgical intervention may be simultaneously undertaken to either compensate or modify the nasomaxillary complex. Maxillary impaction in patients with a wide alar base may result in exacerbation of nasal form unless alar base cinching, Weir resection, or tip modification is performed. Conversely, patients with a narrow alar base, prominent lower lateral cartilages. and a ptotic tip undergoing maxillary impaction will greatly benefit from minor rhinoplasty techniques performed in conjunction with the orthognathic surgery. In such cases, it is important to be conservative and inform the patient of the potential benefits and alterations from such surgery. Simultaneous orthognathic and rhinoplastic procedures can be predictably performed with good results when the proper indications are identified. It is essential to have a thorough understanding of both rhinoplasty and orthognathic techniques. The combination of these procedures can benefit or complicate the situation depending on how they are performed. Common sense, precise planning, and accurate surgery will often result in a complimentary improvement of function and esthetics. References 1. Waite P, Matukas V, Sawer D: Simultaneous rhinoplasty procedures in orthognathic surgery. Int J Oral Maxillofac Surg 17:298, 1988
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2. Powell N, Humphreys B: Proportions of the Aesthetic Face. New York. NY. Theime-Stratton, 1984. D 59 3. Dann JJ, Fonseca ‘RJ, Bell WH: Soft tissue-changes associated with total maxillary advancement: A preliminary study. J Oral Surg 34: 19, 1976 4. Freihofer HP: The lip profile after correction of retromaxillism in cleft and non-cleft patients. J Maxillofac Surg 14:301, 1986 5. Radney LJ, Jacobs JD: Soft tissue changes associated with surgical total maxillary intrusion. Am J Orthod 80:191, 1981 6. Carlotti AE, Aschaffensburg PH, Schendel SA: Facial changes associated with surgical advancement of the lip and maxilla. J Oral Maxillofac Surg 44593, 1986 7. Stella JP, Streater MR, Epker BN, et al: Predictability of upper lip soft tissue changes with maxillary advancement. J Oral Maxillofac Surg 47:697, 1989
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8. Schendel SA, Williamson LW: Surgical maxillary superior repositioning and the facial muscles. J Oral Surg 41:235, 1983 9. Gassmann CJ, Nishioka GJ, Van Sickels JE, et al: A lateral cephalometric analysis of nasal morphologh following Le Fort I osteotomy applying photometric analysis techniques. J Oral Maxillofac Surg 47:926, 1989 10. Webster RC: Advances in surgery of the tip intact rim cartilage techniques and the tip-columella-lip esthetic complex, symposium of corrective rhinoplasty. Otolaryngol Clin North Am 8:615, 1975 11. McCollough EG, Mangat D: Systematic approach to correction of the nasal tip in rhinoplasty. Arch Otolaryngol 107:12, 1981 12. Anderson JR, Ries WR: Rhinoplasty: Emphasizing the External Approach. New York, NY, Thieme, 1986, pp 65-72
