- Email: [email protected]
without minimal hump deformity
Journal of Plastic, Reconstructive & Aesthetic Surgery (2010) 63, e749ee751
CORRESPONDENCE AND COMMUNICATION Asymmetric nasal bone trim: A surgical technique for the deviated nose with/without minimal hump deformity Dear Sir, The deviated nose is still one of the most challenging problem in rhinoplasty. The deviation of the nose may involve the bony vault, the cartilaginous vault, or a combination of both of them. The deviation of the bony pyramid is categorised as: (i) a deviation of the bony pyramid from the aesthetic midline without any asymmetry of the nasal bones, (ii) a deviated pyramid with hump deformity, (iii) a deviated bony pyramid with asymmetry of the nasal bones.1,2 The vast majority of cases with a deviated nose are categorised into the second group, in which moderate to significant hump deformity is present. On the other hand, the deviated nose with or without minimal hump deformity is uncommon, and only a few surgical techniques were presented for the management of this problem.3,4 Herein, we describe a simple and reliable surgical technique named ‘asymmetric nasal bone trim’ which is effective for the management of the deviated nose with or without minimal hump deformity. We especially prefer to perform ‘asymmetric nasal bone trim’ as a part of external septorhinoplasty, which allows a better exposure of the nasal dorsum and septum, and a more accurate detection of the deviated structures. Therefore, transcolumellar and infracartilaginous incisions, identification of the lower and upper lateral cartilages, and dorsum of the nasal bones were performed initially. Thereafter, bilateral mucoperichondrial and mucoperiosteal flaps were elevated over the septum, thereby the mucosal attachments were released completely. The deviated structures in nasal septum were removed/reshaped and septum was straightened. A cartilage graft was obtained from quadrangular cartilage without violating the nasal framework. Bilateral paramedian and lateral osteotomies were performed, thus both nasal bones were totally mobilised to bring the nose back to the midline (Figure 1A and B). The nose was reevaluated and the dorsal profile
was precisely analysed. Subsequently, the ‘asymmetric nasal bone trim’ was performed by trimming the redundant upper lateral cartilage and bone from the concave side using a blade and Kazanjian nasal hump forceps (Karl Storz e 469000) (Figure 1C and D, Figure 2A). Trimmed bony structure might be implanted to the convex side, if necessary (Figure 2B). Uni- or bilateral spreader grafts were placed for the realignment of the middle vault. Finally, septal surgery, paramedian and lateral osteotomies, total mobilisation of the nasal bones, ‘asymmetric nasal bone trim’ and spreader grafts provided a correction in the deviated nose with or without minimal hump deformity. Tipplasty and other grafting procedures were performed depending on the other deformities. A continuous quilting transfixion suture was performed on the septal mucoperichondrium. The inverted V-shaped transcolumellar incision and the infracartilaginous incisions were sutured. Bilateral intranasal splints (Doyle septal splint, Invotec International, Inc., Jacksonville, FL, USA) were used to compress the mucosal septal flaps. The nose was taped and dressed by nasal splint (Denver nasal splint, Micromedics Inc., St. Paul, MN, USA). The realignment of the bony pyramid constitutes one of the critical stages in the surgical correction of the deviated nose. Traditionally, sequential medial and lateral osteotomies, and fine rasping are suggested for the correction of the deviated nose with or without minimal hump deformity. Although it may seem as if it is a good choice for equalising the heights of the nasal bones, this may not be achieved in many cases. Because, as the nasal bones are straightened in the aesthetic midline without any dorsal reduction, the dorsal profile of the bony pyramid will be asymmetric. This is mainly caused due to the unequal lengths of the concave and convex sides. Therefore, a dorsal reduction e especially for the concave side e is required. Unfortunately, fine rasping is generally inadequate for dorsal reduction, and likewise effective dorsal resection of the nasal bones using osteotome cannot be performed due to the mobilisation of the nasal bones. Considering these, we suggest this technique, in which excess segment of the concave side is trimmed using a blade and Kazanjian nasal hump forceps after the application of paramedian and lateral osteotomies. In addition, the trimmed bony structure can be implanted on the convex side, if required. Finally, the rest of the nasal bones can be smoothened by fine rasping
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.04.050
e750
Correspondence and communication
Figure 1 The execution of right paramedian osteotomy(A), the design of lateral osteotomies (B), the excision of redundant cartilage from upper lateral cartilage (C), and trimming of the excess bone from nasal bone (D).
Correspondence and communication
e751 only a nasal hump forceps or a bone cutting forceps is sufficient.
Conflict of interest None.
Funding None.
References
Figure 2 The schematic drawing of ‘asymmetric nasal bone trim’. An excess segment from the concave side is trimmed using a blade and Kazanjian nasal hump forceps after the execution of paramedian and lateral osteotomies (A), Trimmed cartilage-bony structure can be implanted on the other side, if necessary (B).
especially in the cases with thin skin. As a result, ‘asymmetric nasal bone trim’ has many advantages such as: (i) a symmetric nasal vault can be successfully restored in cases with the deviated nose with or without minimal hump deformity, (ii) it can be easily performed even by inexperienced surgeons, (iii) the potential risk of complications is minimal, (iv) the surgeon does not need many instruments;
1. Byrd SH, Salomon J, Flood J. Correction of the crooked nose. Plast Reconstr Surg 1998;102:2148e57. 2. Hsiao YC, Kao CH, Wang HW, et al. A surgical algorithm using open rhinoplasty for correction of traumatic twisted nose. Aesthetic Plast Surg 2007;31:250e8. 3. Huizing EH, de Groot JAM. Pyramid surgery. In: Huizing EH, de Groot JAM, editors. Functional Reconstructive Nasal Surgery. Stuttgart: Thieme; 2003. p. 192e238. 4. Burm JS. Correction of the Asian deviated nose with no hump using unilateral bony mobilisation and dorsal septal suture fixation. J Plast Reconstr Aesthet Surg 2007;60:180e7.
¨ nlu H. Halis U ¨ Go ¨rkem Eskiizmir Department of Otolaryngology-Head Neck Surgery, Celal Bayar University, Manisa 45010, Turkey E-mail address: [email protected]
CORRESPONDENCE AND COMMUNICATION Asymmetric nasal bone trim: A surgical technique for the deviated nose with/without minimal hump deformity Dear Sir, The deviated nose is still one of the most challenging problem in rhinoplasty. The deviation of the nose may involve the bony vault, the cartilaginous vault, or a combination of both of them. The deviation of the bony pyramid is categorised as: (i) a deviation of the bony pyramid from the aesthetic midline without any asymmetry of the nasal bones, (ii) a deviated pyramid with hump deformity, (iii) a deviated bony pyramid with asymmetry of the nasal bones.1,2 The vast majority of cases with a deviated nose are categorised into the second group, in which moderate to significant hump deformity is present. On the other hand, the deviated nose with or without minimal hump deformity is uncommon, and only a few surgical techniques were presented for the management of this problem.3,4 Herein, we describe a simple and reliable surgical technique named ‘asymmetric nasal bone trim’ which is effective for the management of the deviated nose with or without minimal hump deformity. We especially prefer to perform ‘asymmetric nasal bone trim’ as a part of external septorhinoplasty, which allows a better exposure of the nasal dorsum and septum, and a more accurate detection of the deviated structures. Therefore, transcolumellar and infracartilaginous incisions, identification of the lower and upper lateral cartilages, and dorsum of the nasal bones were performed initially. Thereafter, bilateral mucoperichondrial and mucoperiosteal flaps were elevated over the septum, thereby the mucosal attachments were released completely. The deviated structures in nasal septum were removed/reshaped and septum was straightened. A cartilage graft was obtained from quadrangular cartilage without violating the nasal framework. Bilateral paramedian and lateral osteotomies were performed, thus both nasal bones were totally mobilised to bring the nose back to the midline (Figure 1A and B). The nose was reevaluated and the dorsal profile
was precisely analysed. Subsequently, the ‘asymmetric nasal bone trim’ was performed by trimming the redundant upper lateral cartilage and bone from the concave side using a blade and Kazanjian nasal hump forceps (Karl Storz e 469000) (Figure 1C and D, Figure 2A). Trimmed bony structure might be implanted to the convex side, if necessary (Figure 2B). Uni- or bilateral spreader grafts were placed for the realignment of the middle vault. Finally, septal surgery, paramedian and lateral osteotomies, total mobilisation of the nasal bones, ‘asymmetric nasal bone trim’ and spreader grafts provided a correction in the deviated nose with or without minimal hump deformity. Tipplasty and other grafting procedures were performed depending on the other deformities. A continuous quilting transfixion suture was performed on the septal mucoperichondrium. The inverted V-shaped transcolumellar incision and the infracartilaginous incisions were sutured. Bilateral intranasal splints (Doyle septal splint, Invotec International, Inc., Jacksonville, FL, USA) were used to compress the mucosal septal flaps. The nose was taped and dressed by nasal splint (Denver nasal splint, Micromedics Inc., St. Paul, MN, USA). The realignment of the bony pyramid constitutes one of the critical stages in the surgical correction of the deviated nose. Traditionally, sequential medial and lateral osteotomies, and fine rasping are suggested for the correction of the deviated nose with or without minimal hump deformity. Although it may seem as if it is a good choice for equalising the heights of the nasal bones, this may not be achieved in many cases. Because, as the nasal bones are straightened in the aesthetic midline without any dorsal reduction, the dorsal profile of the bony pyramid will be asymmetric. This is mainly caused due to the unequal lengths of the concave and convex sides. Therefore, a dorsal reduction e especially for the concave side e is required. Unfortunately, fine rasping is generally inadequate for dorsal reduction, and likewise effective dorsal resection of the nasal bones using osteotome cannot be performed due to the mobilisation of the nasal bones. Considering these, we suggest this technique, in which excess segment of the concave side is trimmed using a blade and Kazanjian nasal hump forceps after the application of paramedian and lateral osteotomies. In addition, the trimmed bony structure can be implanted on the convex side, if required. Finally, the rest of the nasal bones can be smoothened by fine rasping
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.04.050
e750
Correspondence and communication
Figure 1 The execution of right paramedian osteotomy(A), the design of lateral osteotomies (B), the excision of redundant cartilage from upper lateral cartilage (C), and trimming of the excess bone from nasal bone (D).
Correspondence and communication
e751 only a nasal hump forceps or a bone cutting forceps is sufficient.
Conflict of interest None.
Funding None.
References
Figure 2 The schematic drawing of ‘asymmetric nasal bone trim’. An excess segment from the concave side is trimmed using a blade and Kazanjian nasal hump forceps after the execution of paramedian and lateral osteotomies (A), Trimmed cartilage-bony structure can be implanted on the other side, if necessary (B).
especially in the cases with thin skin. As a result, ‘asymmetric nasal bone trim’ has many advantages such as: (i) a symmetric nasal vault can be successfully restored in cases with the deviated nose with or without minimal hump deformity, (ii) it can be easily performed even by inexperienced surgeons, (iii) the potential risk of complications is minimal, (iv) the surgeon does not need many instruments;
1. Byrd SH, Salomon J, Flood J. Correction of the crooked nose. Plast Reconstr Surg 1998;102:2148e57. 2. Hsiao YC, Kao CH, Wang HW, et al. A surgical algorithm using open rhinoplasty for correction of traumatic twisted nose. Aesthetic Plast Surg 2007;31:250e8. 3. Huizing EH, de Groot JAM. Pyramid surgery. In: Huizing EH, de Groot JAM, editors. Functional Reconstructive Nasal Surgery. Stuttgart: Thieme; 2003. p. 192e238. 4. Burm JS. Correction of the Asian deviated nose with no hump using unilateral bony mobilisation and dorsal septal suture fixation. J Plast Reconstr Aesthet Surg 2007;60:180e7.
¨ nlu H. Halis U ¨ Go ¨rkem Eskiizmir Department of Otolaryngology-Head Neck Surgery, Celal Bayar University, Manisa 45010, Turkey E-mail address: [email protected]