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British Journal of Oral and Maxillofacial Surgery 52 (2014) 980–982
Technical note
Osteochondral nasal dorsum flap in open rhinoplasty Albino Triaca a,1 , Alexander Gaggl b , Farzad Borumandi b,∗ a b
Center for Maxillofacial Surgery, Pyramide Clinic, Zurich, Switzerland Department of Oral and Maxillofacial Surgery, Paracelsus Medical University, Salzburg, A- 5020 Austria
Accepted 18 August 2014 Available online 4 September 2014
Keywords: Rhinoplasty; Open roof; Spreader graft; Spacer graft
Introduction
Surgical technique
The dorsum of the nose can be reconstructed in many ways, usually with satisfactory results.1 Many patients require correction of the upper lateral cartilages to improve the shape from the anteroposterior view and in profile. Care must be taken with the horizontal and vertical reduction of the upper lateral cartilages. To avoid over-resection, it should be begun after the osteotomies have been completed, as the upper lateral cartilages will drop down after the nasal bones have been repositioned.2 Substantial reduction of the upper lateral cartilages may result in the roof of the nose requiring spacer grafts at the rhinion to fill the gap. Spreader grafts may also be required to lateralise the upper lateral cartilages from the septum either to widen the nose aesthetically or support the upper lateral cartilages, which may narrow the internal valve.2 Over-resection of the dorsum has been reported to be one of the main complaints that lead to revision rhinoplasty,3 which may be demanding when the dorsum has been altered and scarred after the primary operation.4 We present what is to our knowledge a new technique for preservation of the original structures of the dorsum of the nose in open rhinoplasty.
The dorsum is approached by the well-known transcolumellar approach with subcutaneous dissection to leave the dermal and subdermal plexus intact.5 The nasal superficial musculoaponeurotic system (SMAS) is then dissected, and protected during further dissection (Fig. 1). Next, the upper part of the nasal bone is cut bilaterally and cranially (Fig. 2). The osteotomy may be made with an ultrasonic device (Piezosurgery®). The upper lateral cartilages are cut bilaterally at the same level as the osteotomy line of the nasal bone. The osteochondral flap, which is composed of a small part of the nasal bone cranially and the upper lateral cartilages inferiorly, is raised and rotated anteriorly (Fig. 3). The subjacent nasal compartments can then be reshaped and contoured as needed. Once the nasal modelling has been completed, the osteochondral flap is trimmed according to the newly-shaped dorsum, and sutured back into place to cover the nasal roof (Fig. 4). The dissected SMAS flap is repositioned to cover any minor irregularities. After the nasal tip has been reshaped, the transcolumellar incision is closed. If the osteochondral flap is dissected during open rhinoplasty, the original anatomy of the dorsum can be preserved without the need for additional spacer or spreader grafts. The projection of the nasal tip can be modified if the flap is sutured back more cranially.
∗
Corresponding author. Tel.: +43 664 733 22 172; fax: +43 662 4482 884. E-mail addresses: [email protected] (A. Triaca), [email protected] (F. Borumandi). 1 Tel: +41 44 388 14 88
Conflict of interest We have no conflict of interest.
http://dx.doi.org/10.1016/j.bjoms.2014.08.012 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
A. Triaca et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 980–982
Fig. 1. The superficial musculoaponeurotic system (SMAS) flap dissected off the nasal dorsum. It is used to cover minor irregularities at the end of the procedure.
Fig. 2. The osteotomy of the nasal bone for dissection of the osteochondral flap.
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Fig. 3. The osteochondral flap is raised and rotated anteriorly.
Fig. 4. The anatomical reconstruction of the dorsum. The osteochondral flap is sutured back between the upper lateral cartilages and the nasal bones to cover the roof of the nose. The projection of the nasal tip can be modified by craniocaudal repositioning of the flap.
982
A. Triaca et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 980–982
Ethics statement/confirmation of patient’s permission Not required. References 1. Lee MR, Unger JG, Rohrich RJ. Management of the nasal dorsum in rhinoplasty: a systematic review of the literature regarding technique, outcomes, and complications. Plast Reconstr Surg 2011;128:538e–50e.
2. Adamson PA, Warren J, Becker D, et al. Revision rhinoplasty: panel discussion, controversies, and techniques. Facial Plast Surg Clin North Am 2014;22:57–96. 3. Constantian MB. Differing characteristics in 100 consecutive secondary rhinoplasty patients following closed versus open surgical approaches. Plast Reconstr Surg 2002;109:2097–111. 4. Pearlman SJ, Talei BA. An anatomic basis for revision rhinoplasty. Facial Plast Surg 2012;28:390–7. 5. Arslan E, Gencel E, Pekedis O. Reverse nasal SMAS-perichondrium flap to avoid supratip deformity in rhinoplasty. Aesthetic Plast Surg 2012;36:271–7.
British Journal of Oral and Maxillofacial Surgery 52 (2014) 980–982
Technical note
Osteochondral nasal dorsum flap in open rhinoplasty Albino Triaca a,1 , Alexander Gaggl b , Farzad Borumandi b,∗ a b
Center for Maxillofacial Surgery, Pyramide Clinic, Zurich, Switzerland Department of Oral and Maxillofacial Surgery, Paracelsus Medical University, Salzburg, A- 5020 Austria
Accepted 18 August 2014 Available online 4 September 2014
Keywords: Rhinoplasty; Open roof; Spreader graft; Spacer graft
Introduction
Surgical technique
The dorsum of the nose can be reconstructed in many ways, usually with satisfactory results.1 Many patients require correction of the upper lateral cartilages to improve the shape from the anteroposterior view and in profile. Care must be taken with the horizontal and vertical reduction of the upper lateral cartilages. To avoid over-resection, it should be begun after the osteotomies have been completed, as the upper lateral cartilages will drop down after the nasal bones have been repositioned.2 Substantial reduction of the upper lateral cartilages may result in the roof of the nose requiring spacer grafts at the rhinion to fill the gap. Spreader grafts may also be required to lateralise the upper lateral cartilages from the septum either to widen the nose aesthetically or support the upper lateral cartilages, which may narrow the internal valve.2 Over-resection of the dorsum has been reported to be one of the main complaints that lead to revision rhinoplasty,3 which may be demanding when the dorsum has been altered and scarred after the primary operation.4 We present what is to our knowledge a new technique for preservation of the original structures of the dorsum of the nose in open rhinoplasty.
The dorsum is approached by the well-known transcolumellar approach with subcutaneous dissection to leave the dermal and subdermal plexus intact.5 The nasal superficial musculoaponeurotic system (SMAS) is then dissected, and protected during further dissection (Fig. 1). Next, the upper part of the nasal bone is cut bilaterally and cranially (Fig. 2). The osteotomy may be made with an ultrasonic device (Piezosurgery®). The upper lateral cartilages are cut bilaterally at the same level as the osteotomy line of the nasal bone. The osteochondral flap, which is composed of a small part of the nasal bone cranially and the upper lateral cartilages inferiorly, is raised and rotated anteriorly (Fig. 3). The subjacent nasal compartments can then be reshaped and contoured as needed. Once the nasal modelling has been completed, the osteochondral flap is trimmed according to the newly-shaped dorsum, and sutured back into place to cover the nasal roof (Fig. 4). The dissected SMAS flap is repositioned to cover any minor irregularities. After the nasal tip has been reshaped, the transcolumellar incision is closed. If the osteochondral flap is dissected during open rhinoplasty, the original anatomy of the dorsum can be preserved without the need for additional spacer or spreader grafts. The projection of the nasal tip can be modified if the flap is sutured back more cranially.
∗
Corresponding author. Tel.: +43 664 733 22 172; fax: +43 662 4482 884. E-mail addresses: [email protected] (A. Triaca), [email protected] (F. Borumandi). 1 Tel: +41 44 388 14 88
Conflict of interest We have no conflict of interest.
http://dx.doi.org/10.1016/j.bjoms.2014.08.012 0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
A. Triaca et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 980–982
Fig. 1. The superficial musculoaponeurotic system (SMAS) flap dissected off the nasal dorsum. It is used to cover minor irregularities at the end of the procedure.
Fig. 2. The osteotomy of the nasal bone for dissection of the osteochondral flap.
981
Fig. 3. The osteochondral flap is raised and rotated anteriorly.
Fig. 4. The anatomical reconstruction of the dorsum. The osteochondral flap is sutured back between the upper lateral cartilages and the nasal bones to cover the roof of the nose. The projection of the nasal tip can be modified by craniocaudal repositioning of the flap.
982
A. Triaca et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 980–982
Ethics statement/confirmation of patient’s permission Not required. References 1. Lee MR, Unger JG, Rohrich RJ. Management of the nasal dorsum in rhinoplasty: a systematic review of the literature regarding technique, outcomes, and complications. Plast Reconstr Surg 2011;128:538e–50e.
2. Adamson PA, Warren J, Becker D, et al. Revision rhinoplasty: panel discussion, controversies, and techniques. Facial Plast Surg Clin North Am 2014;22:57–96. 3. Constantian MB. Differing characteristics in 100 consecutive secondary rhinoplasty patients following closed versus open surgical approaches. Plast Reconstr Surg 2002;109:2097–111. 4. Pearlman SJ, Talei BA. An anatomic basis for revision rhinoplasty. Facial Plast Surg 2012;28:390–7. 5. Arslan E, Gencel E, Pekedis O. Reverse nasal SMAS-perichondrium flap to avoid supratip deformity in rhinoplasty. Aesthetic Plast Surg 2012;36:271–7.
