Total rhinoplasty or prosthesis?

Total rhinoplasty So Eon Ko, D.D.S.,*

or prosthesis?

Louis Fine, B.D.S., H.D.D.,**

Zoller Dental Clinic, University

and John E. Robinson, D.D.S.***

of Chicago, Chicago, Ill.

T

he face is the most important physical manifestation of our beauty-conscious society, and the nose is the most prominent part of the face: When selecting a patient for replacement of a nose by total rhinoplasty or prosthesis, the medical, dental, sociocultural, psychological, and environmental factors should be evaluated.

extraoral fields.’ Norman W. Kingsley, in 1880, and Claude Martin, in 1889, described palatonasal prostheses.’ In 1901, Robert H. Upham” described artificial noses and ears for which he used a soft vulcanized rubber. Louis Ottofy,7 W. H. Baird,’ and Lee Baker” described artificial noses in 1905. V. H. Kazanjian’” described nasal prostheses in 1925.

HISTORY

CAUSES OF DEFECTS OF THE NOSE Congenital

Artificial noses. eyes, ears, and lips were used in ancient India and China, and have been found on EDptian mummies.’ Later, they were used in Greece and Rome. Ambroise Pari: (15 17-1590),’ the famous French surgeon, recommended the use of a prosthetic nose, eye, ear, and palatal obturator. Tycho Brahe (1546-1601), astronomer and mathematician, lost a major part of his nose in a duel. He sought to correct his disfigurement by replacing the missing part of his nose with wax. A mold was made around the piece of wax and the wax was replaced with an alloy of copper (or gold) and silver by the lost-wax process. This produced a metal prosthesis which was painted with oil paint to match his skin. The prosthesis was attached with a glutinous substance which he carried in a small box.’ Pierre Fauchard (1678-1761),’ father of scientific dentistry, greatly influenced maxillofacial prosthetics. His reference to the “Gunner with the Silver Mask” is a classic in the literature. William Morton (1819-1868),” known for his discovery of the use of ether for anesthesia, fabricated a nasal prosthesis of porcelain for a woman in Boston by attaching an artificial nose to her spectacles. Christopher-Francois Delabarre introduced many innovations which have a definite application to maxillofacial prosthetics today, both in the intraoral and

*Resident in Maxillofacial Prosthetics **Associate Professor. Dental Surgerv and Maxillofacial theucs. ***Professor. Dental Surgery and Chief. Maxillofacial thetics

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JULY 1980

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ProsPros-

Congenital deformities of the nose such as fissure, double nose, bifid nose, and cleft noses are rare.lL-’

Trauma The first occasion of traumatic def&t is at birth during delivery. In a study of more than 700 births in white children, the incidence of gross lateral displacement of well-constructed noses was about 6%.‘,’ Most traumatic defects to the nose are caused by burns, accidents while playing, automobile injuries, and gunshot wounds.

Neoplasm Tumors of the nasal cavity are rare and are usually classified and reported jointly with tumors of the paranasal sinuses.“-“’ Some of the etiologic factors which have been mentioned in cancer of the nasal cavity are: atrophic rhinitis, nasal polyp,“. ,I” inhalation of dust in industries such as boot and shoemaking, woodworking and furniture makirlg,‘4. “. ?’ and long-term smoking.” Frazell and Lewis” reported 416 patients with cancer of the nasal cavity and accessory sinuses over a 20-year period. Most primary malignant tumors arising at the nasal cavity and sinus sites are squamous cell carcinoma or adenocarcinoma arising from the mucous glands of the area. The primary malignant tumors of the nasal cavity are usually reported to have a poor prognosis,“.” with the highest incidence occurring in the fifth and sixth decades. The signs and symptoms of

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cancer of the nasal cavity and sinuses are similar to many benign processes.“- ’ They are. therefore, often overlooked in the early stages and treated conservatively. Common symptoms include nasal obstruction, nasal discharge, epistaxis. local pain, and visual disturbance. Neck masses are rarely noted. In a study of 456 patients with cancer of the skin of the nose, Conle)reported an even distribution in the sexes, with the highest incidence again occurring in the fifth and sixth decades. Basal cell cancel comprised 87%, occurring predominantly on the ala, and root. Squamous cell cancer \zas more tip, common on the lateral borders and columella, occurring in 10.7% of the patients. hletastases developed in 0.255 of the basal cell cancers and in 18.5% of squamous cell cancers. The most common etiologic factors were exposure to sunlight and to superficial irradiation.

PSYCHOLOGIC

ASPECT

Loss of nasal structure. wholly or in part, cause many patients to feel personally inadequate and unable to cope \vith the pressures of social life “’ ” (“I don’t like to go out; I don’t have any friends”), marriage, or their job. Obviously, there is a notable esthetic improvement after placement of a nasal prosthesis, but this will not have a positive. decisive influence if the patient is unable to change his psychologic attitude.

RECONSTRUCTION

OF DEFECTS

Most nose defects are corrected by surgery. External defects may be corrected by prostheses or b> reconstructive plastic surgery with local flaps, composite grafts, forehead flaps, or tubed pedicle flaps. The extent and types of defects. as well as the condition of the remaining tissues, determine the choice of rehabilitation. Previous exposure to radiation may prevent the use of remaining tissue OI donor sites. The reconstructed nasal surface must be free of hair and afford a reasonable match of skin color and texture.

ANATOMIC

CONSIDERATIONS

While beauty cannot be measured by a compass or ruler, such basic knowledge is required for constructing a nose. Many of the basic observations on the divisions of the face were originally described in the fifteenth century by Leonardo da Vinci”: The space from the chin to the beginning of bottom of nose (gnathion to subnasale) is the third part of the face.

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DENTISTRY

and equal to the nose (nasion to subnasale), to the forehead (trichion to nasion). The ala nasi occupy the space betkveen the two inner can1 hi. or one eye‘s breadth. The most common profile angle of the nose is 30 degrees. “’ +I’ Ricketts suggested A line which he calls the “esthetic plane” to govern his law of lip relationship, Lvhich is as follows: In whites, by- the age adulthood, the lips should be contained within a line from the chin to the tip of the nose. “’ Simons,” described the ideal 2:l ratio of chin to upper lip (upper lip length: the distance between perpendiculars constructed from subnasale and stomion;* lolver lip length: from stomion and soft tissue menton). The nasal profile should present at least three planes”’ “~“‘: a dorsal plane, a columella plane, and a slanting plane connecting the other t\vo. Esthetically. the ideal dorsal profile line should be straight from the supratip area to the nasion. and the tip should project slightly above this line. In the male, a slight rhinion hump is acceptable; in the female. the opposite is desirable. The ideal base vie\% should be accommodated Lvithin an equilateral triangle in which the base line at the nasolabial angle will be approximately equal to the lines that skirt the lateral Lvalls. The columella should form the center of this triangle. Each naris should ha*.-e an asvmmetric ovoid outline Lvhich is Midest at the base and narrowest to\vard the nasal tip. Its ,-lpex should be rounded. The long axis of the naris should slope fonvard and medially at 45 to 60 degrees. The columella may be convenientlv dlvlded into three parts: the anterior lobular portion, the intermediate narrow part, and the wider basal segment. Each part would be approximatelv equal in lerlgth. The lobular section consists of that part \vhich is situated in front of a line that runs tangential lo the apices of both nares. The wider basal portion corresponds to the lateral flare of the posterior aspects of the medial crura. Bernstein”’ compared the ideal male and female nose (Table I). Studies on nose growth’..‘” agree that growth occurs in a downward and anterior direction. Lvith a yearly increase in nose length of approximately 1.5 mm. Chaconas” observed a more pronounced nasal bridge in Angle Class II subjects than in Class I, whereas Class III subjects revealed a concave configuration of the nose along the dorsum. \V’isth”’ observed that the distance between the tip of the nose and the chin was significantly greater in the *Contact

point

of upper

and lower

lips

75

KO, FINE, AND ROBINSON

Table I. Ideal characteristics

of male and

female noses Male Size

Relatively

Dorsum

CYide dorsum acceptable Convexity acceptable

Dorsal projectton

larger

TIP

Wide ttp acceptable

TIP prelection

90 to 105 Degrees

Nares

Wide nares acceptable

Surface

Textured surface acceptable

Female

Relatively smaller Narrow dorsum destrable Mild convexity acceptable Narrow tip desmble 105 to 120 Degrees

Narrow nares desirable Smooth surface destrable

Class II group, and significantly less in the Class III group when compared to the Class I individuals. A retruded chin would be more harmonious with a smaller upturned nose. whereas a prominent chin could be more harmonious with a greater projection of the nasal dorsum. The tip of the nose, even when the length is normal, seems to droop in individuals with a shallow, receding upper lip. An acute nasolabial angle exaggerates the length of the nose. DISCUSSION Considering the prominence of the nose in the physiognomy. it is easy to recognize the difficulty that skilled plastic surgeons would have in developing a series of operations to produce an acceptable esthetic result in a patient having undergone a total rhinectomy. Total rhinoplasty requires a new lining, supporting framework, and cover (or outer surface) of the nose. Such procedures often begin with the development of a tubed pedicle from the forehead or deltopectoral area to create the necessary bulk. Internal structures of cartilage for the support of the bridge of the nose, columella, and ala could not be provided until recent times. Research and development of microvascular surgical techniques have improved the potential for surgical reconstruction. In one method,” the lining is made from local flaps, the framework is made from the second metatarsal bone, and the cover is made from a free dorsalispedis skin graft. Limited experience with this technique has produced some favorable results. While most patients prefer to be reconstructed with their own tissues, time, money, and/or physiologic compromise may not allow this. 76

Before constructing a nasal prosthesis, a pleasing, harmonious contour and expression of the entire face should emerge in one’s visual mind. The maxillofacial prosthodontist must consider many facial features in the fabrication of a nasal prosthesis. The prosthesis must conform with the other bony and soft tissue contours such as the eyes, lips, forehead, chin, and the relative position of the rnasilla to the mandible. In the elderly individual with loss of teeth and alveolar structures, nasal support is lost and the nose tends to lengthen. Replacing absent or defective tee1 h with proper dentures improves lip posture and helps disguise the drooping, elongated nasal profile in the elderly. Dentures should be provided before any attempt at reconstruction is made. In the hands of an experienced maxillofacial prosthodontist. rehabilitation of the total rhinectomy patient can result in a favorable esthetic result in most cases. Control of anatomy is not a problem, and a pattern can be developed and modilied to produce the best possible esthetic result to fit the surgical defect. In selected patients, plastic surgery can offer valuable adjunctive procedures to provide a firm base for support of the prosthesis. This is particularly true if a thin band of tissue remains as the upper lip. Mobilization of local flaps can often I-educe the size of the defect, thus allowing for a lighter and smaller prosthesis. Prostheses do have shortcomings, hobvever. and the patient should be made aware of this. Daily removal and reapp&tion can bec0rr.e bothersome, and in compromised tissue, there may be cause for close observation. SUMMARY This article outlines the basic anatomy of the nose as it relates to a pleasing facial appearance and discusses the problems involved in the reconstruction and rehabilitation of the patient sustaining total rhinectomy. REFERENCES Popp. P H : Zur Geschichte der prothere, Dte Med h’elt 13:961, 1939 Par-~. A The IVorkes of That Famous Chirurgion Ambre Pare! Translated out of Latine and compared with the French by Tho Johnson, London, Richard Cotes and Wllli Du-gard.

1649

Lee. D C : Tycho Brahe and his sixteenth century nasal prosthesis. Plast Reconstr Surg 50:332, 1972 Fauchard. P : Le chirurglen dent&e ou tralr.4 des dents. ed 2. Parls. 1746 Bulbulian, A H Maxillofacial prosthetic;: Evolution and JULY 1980

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6. 7. 8. 9 10. 11.

12.

13. 14.

15. 16. 17. 18

19

20.

21.

22.

23 24.

25. 26. 27. 28.

29.

OR PROSTHESIS7

practical appltcatton m patient rehabilitation. J PROSTHET DENT 15:554. 1965 Upham, R. H: Artificial noses and ears. Boston Med and

30

Surg J Ottofy. c;osmos Baird. 19tr5 Baker. 47:561.

31

145:52.!. 1901 L: An artifictal nose for a Chmaman. 47:558. 1905. \V H An artificial nose. Dental Cosmos L. An 1905

artificial

nose and

palate

Dental

Dental 47:560. Cosmos 33.

KazanJian. 1. H : Treatment of nasal deformities J Am Mrd Assoc 843177. 1925 Cohen, hi. hl : Frontonasal dysplasia (median cleft face swdrome): Comments on etiology and pathogenesis. Birth Defect% 7:117. 1971 F&de. R: Ubcr phvslologwzhe Euryople und pathologischen hypertelorlsmus ocular~s. Graefe Arch Klin Exp Ophth 155:359. 1954 Petterson. G. Deformities and defect of the nose in children. Acta Chil Stand 107:539. 1954 Rugel. S, sod Keates. E \Vaardenburg’s syndrome in SIX generations of one family Am J Dis Child 109. June 1965 Boo-Chai, K The bifid nose wth a report of 3 cases m siblings. Plast Reconstr Surg 36:626, 1965 Montford. T. Hereditary hypertelortsm wtthout mental deficiency. Arch Dis Child 4:381, 1929. Gillespie, F. D Hereditary syndrome “Dysplasia oculodentodigltahs.” Arch Ophthal (ChIcago) 71:187, 1964. Hopkins. G. B : Hypoplasia of the middle third of the face associated wth congenltal absence of the anterior nasal spine. depresslon of the nasal bone, and Angle Class III malocclusion Br J Plast Surg 16:146, 1963. LVarkanv. J.. Bofinger. hl . and Benton. C. hledian facial cleft 5) ndrome in half-sisters’ dilemmas m genetlc counselmg. Teratology 9:273, 1973 Fok. J 1%‘. Golden. G. T . and Edgerton, hl. T Fronronasal dysplasia with alar clefts in two sisters. Plast Reconstr Surg 57:553, 1’176. Johanson. A. and Bhzzard, R : A syndrome of congenttal aplasla of the alae nast. deafness. hypothyroidism, dwarfism, absent permanent teeth. and malabsorption. J Pediatr 79:982. 1971 Pinsky. L . and DlGeorge. A.: A familial syndrome of facial and skeletal anomalies associated with genital abnormalit) m the male and normal genttals m the female. J Pediatr 66:1049, 1965 Sterner. h : Certain aspects of nasal trauma m the prenatalnatal period Eye. Ear. Nose hlonthh 39:419. 1960 Frazell. E. L . and Lewis. J J Cancer of nasal cavity and accessory sinuses-Report of management of 416 pattents Cancel 16:1293, 1963. Ohver. P. Cancer of the nose and paranasal sinuses, Surg Clm North Am 47:595. 1967 Letfall L D.. and \Vhite, J. E.. Cancer of the nasal cawtv and paranasal sinuses. Am J Surg 112:436, 1966. Lewis. J. S., and Castro. I:. B.: Cancer of the nasal cavity and palanasal sinuses. J Laryngol Otol 86:255, 1972. Haynes. \V. D., and Tapley. N. \‘.: Radiation therapy of carcmoma of the nasal vestibule. Am J Roent Rad Ther Nuci Med 120:595. 1974 Buchanan, G . and Slawn, G.: Tumors of the nose and smuscs. A chmcopathological study. J Laryngol Otol 86:685, 1972

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34. 35. 36 37

38.

Badib. A. O., Kurohara, S. S., Webster, J. H., and Shed. D. P : Treatment of cancer of the nasal cavity Am J Roent Rad Ther Nucl hled 106:824, 1969. Acheson. E. D., Cowdell, R H., Hadfield, E., and Macbeth, R G.. Nasal cancer in woodworkers in the furniture industry Br Med J 2:587, 1968. Acheson. E. D., Cowdell, R. H , and Jolles. B.: Nasal cancer m the Northhampshtre boot and shoe industry. Br Med J 1:385. 1970 Bosch, .I, C’alleclllo, L., and Frtas, Z. Cancer of nasal cavity. Cancer 37:1458. 1976. Bomrr, D. L . and Arnold. G E Rare tumors of the ear. nose. and throat Acta Oto-larwgol 289:l. 1971 (Suppl) Conlcy, J : Cancer of the skin of the nose Ann Otol Rhino1 Lar)ngol 82:2, 1974 Brittle, R hf Psychlatrlc evaluatton of patients seeking rhinoplasty Otolaryngol Chn North :\m 8:689, 1975 Steward, hl.: Psychosocral problems of patients requesting rhinopiastv Tram Am Acad Ophth.11 Otolaryng 68:881. 1964 \Vorks of Leonardo da \‘incl. New Rlcheter. J. P Literary York, 1939, Oxford Press, vol I, p 308.

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Hambleton. R face as related 50:405, 196-L

40.

Bernstein, L Esthetic anatomy of th: nose. Larvngoscope 82:1323. 1972 Smlons, R L : Adjunctlve measures m rhinoplasty Otolaryngol Chn North Am 8:717. 19i5 \Vrlght, I\‘. K.: Symposium The supra-tip m rhmoplasty A dilemma II Influence of surrounding structure and preventlon LarTngoscope 86:50, 1976

41 $2.

43

44. 45 46 47 48

49 50.

51

S. The soft-tissue co+wmg to orthodontic problems

of the skeletal Am J Orthod

Anderson, J R.: Supratlp soft-tissue rounding after rhinoplatrv Cauws. prevention and treal ment Laryngoscope 86:53, 1976 Lutledge. L J Surgical anatomy 01 the nose. Eye, Ear. Nose. Throat Monthly 42:28. 1963. Peck. H., and Peck. S.: A concept of facial esthettcs. Angle Orthod 40:284, 1970. GranLille, E 1.. Nasal shape. prognathism, and adaptation In man Am J Phys Anthrop 30:29. 1969 Chaconas. S J : A statIstica evaluatlorl of nasal growth. Am J Orthod 56:403. 1969 Subtelny. J D .A longitudinal stud;. of soft-tissue facial structures and their profile charactettrtics, defined m relanon 10 underl\ing skeletal structures .\m ,J Orthod 45:481. 1959 [Visth. P J Changes of the soft-tissue profile during growth Trans Europ Orthod Sot 48:123. 197; \Vlsth. P J Nose morphology in individuals with Angle Class I. Class II. or Class III occlusion Acta Odontol Stand 33:53, 1975 Ohmori, K. Seklguchi, J.. and Ohmorl. S Total rhmoplastv xvlth a free o\teocutaneous 1979

flap

Plast Reconsrr

Surq 63:387.

Refmt rrqwstJ to. DR So EON Ko UNIVERSITY OF CHICAGO HOSPITALS *ND CLINICS !\‘L\LTER G Zor LFR hIEMoRtI\L DENTAL Ct.r~rc 950 E 59w ST. CHICAGO. 1~1.. 60637

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