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Esthetic and Anatomic Basis of Modified Lateral Rhinotomy Approach
J Oral Maxillofac Surg 67:231-234, 2009
Esthetic and Anatomic Basis of Modified Lateral Rhinotomy Approach Krishnakumar Thankappan, MBBS, MS, DNB,* Rajeev Sharan, MBBS, MS,† Subramania Iyer, Mch, FRCS,‡ and Moni Abraham Kuriakose, MD, FRCS, FDSRCS, FFDRCS§ Lateral rhinotomy is an established approach to the midfacial skeleton.1-3 The standard incision for lateral rhinotomy is placed in the nasofacial groove (Fig 1). This is not without complications.4,5 Several modifications of the incision have been proposed to improve the esthetic results.6,7 We describe the esthetic and anatomic basis for this modified incision and analyze the esthetic outcome of the technique.
corners are accurately aligned at the time of the closure. This is a retrospective review of all patients who have undergone the modified lateral rhinotomy approach during a period of 36 months from March 2004 to February 2007. This approach was used for maxillectomy and craniofacial resections. In craniofacial resections this was used as the transfacial incision for medial maxillotomy to access the nasoethmoid tumors. During the study period 22 patients underwent this procedure. The minimum follow-up was a period of 6 months. Esthetic outcome was evaluated by reviewing the medical records, patient photographs (Figs 3, 4), and by clinical examination at follow-up. The presence of any cosmetic problems like hypertrophic scar, alar blunting, ectropion, telecanthus, or lower lid edema was noted.
Patients and Methods The modified lateral rhinotomy incision (Fig 2) consists of making a vertical incision between the dorsal and lateral esthetic nasal subunits. The incision is extended along the lateral alar groove to the floor of the nose and then if lip split is required it exits the nasal cavity, leaving a triangular notch in the floor of the nasal cavity. A “V” is incorporated in the incision at the midpoint between the dorsum and the medial canthus. The flap is harvested laterally in the subperiosteal plane. The incision can be extended superiorly or laterally along the subciliary line. The subciliary extension is but rarely indicated. For extension to the medial orbital wall, it is necessary to isolate and detach the medial canthus, which is tagged at the time of incision and later attached to the bone. Upper lip split if necessary is made through the midline. Closure is performed in 2 layers. All the angles and
Results The modified lateral rhinotomy approach was carried out in 9 cases of maxillectomy and 13 cases of craniofacial resections. Table 1 shows the details. The esthetic outcome is listed in Table 2. None of the patients had hypertrophic scar along the incision, alar blunting, or lower lid edema. Two cases where subciliary extension was done had minimal ectropion. One patient of craniofacial resection had telecanthus, but this was due to the detachment of the medial canthus from its bony attachment and not related to the incision. None of the patients complained of an unesthetic scar.
*Fellow in Head and Neck Surgery, Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, India. †Fellow in Head and Neck Surgery, Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, India. ‡Consultant, Head and Neck, and Chief, Department of Plastic and Reconstructive Surgery, and Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, India. §Chairman and Head, Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, India. Address correspondence and reprint requests to Dr Kuriakose: Head and Neck Surgery, Amrita Institute of Medical Sciences, Elamakkara, Kochi, Kerala 682026, India; e-mail: akuriakose@aims. amrita.edu
Discussion Lateral rhinotomy with its various extensions is widely used to approach the midfacial skeleton and the anterior skull base. The classical lateral rhinotomy approach does not follow the esthetic facial subunit principle as well as it causes the disruption of the musculature around the nose. Although it provides reasonable esthetic outcome the result can be improved significantly by following the esthetic and anatomic principles of midface. Understanding the importance of facial subunits and facial skin creases, a
© 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6701-0037$34.00/0 doi:10.1016/j.joms.2008.07.012
231
232
MODIFIED LATERAL RHINOTOMY APPROACH
FIGURE 1. Standard lateral rhinotomy incision. Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
modification has been described.6,7 The modification attempts to improve the facial appearance, facial expression, and to make the incision inconspicuous.6 This report critically evaluates the esthetic outcome of this modified approach. The muscles that constitute the soft lateral wall of the nose can be divided into a group of “intrinsic muscles” and extrinsic muscles (Fig 5). The extrinsic
FIGURE 3. Esthetic outcome, patient photograph 1. Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
FIGURE 2. Modified lateral rhinotomy incision. Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
muscles include levator labii superioris alaeque nasi, zygomaticus minor, and orbicularis oris. The intrinsic muscles include the procerus, nasalis, depressor septi, dilator naris anterior, compressor narium minor, and depressor alae nasi. Their common insertion is near the alar base.8 The procerus muscle, having its origin mainly on the bony vault of the nose and inserting in the skin of the forehead region between the eyebrows,9 sometimes has bundles running over the nasalis muscle all the way to the end of the nose.10 This muscle is oriented along the long axis of the dorsum. The levator labii superioris alaeque nasi originates in the glabellar region, runs inferolaterally, and gets inserted near the alar base. The conventional lateral rhinotomy incision cuts through the levator labii superioris alaeque nasi, and this may be one of the reasons for the widening of the scar caused by this incision. The modified incision runs along the procerus muscle lateral to it without transverse cutting of the levator labii superioris alaeque nasi except near its
233
THANKAPPAN ET AL
FIGURE 5. Muscles of the nose. Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
insertion. Scar stretching will be minimal in this situation. The face is made up of various esthetic units, and these units have their subunits. The esthetic subunit principle is being used increasingly in reconstructive facial surgery to achieve better cosmetic outcomes. The nose is 1 of the esthetic units of the face and is FIGURE 4. Esthetic outcome, patient photograph 2. Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
Table 1. PATIENT DETAILS
Facial Incision
Maxillectomy (Number of Patients)
Craniofacial Resection (Number of Patients)
0
6
4
2
2
1
3 9
4 13
Lateral rhinotomy Weber-Ferguson (lateral rhinotomy with lip split) Weber-Ferguson with Lynch extension Weber-Ferguson with subciliary extension Total
Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
Table 2. ESTHETIC PROBLEMS
Esthetic Problem
Number of Patients
Hypertrophic scar Alar blunting Ectropion Telecanthus Lower lid edema
0 0 2 1 0
Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
FIGURE 6. Facial esthetic subunits. Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
234 made up of smaller subunits of slightly convex and concave surfaces separated by shallow valleys and ridges.11 These subunits are the dorsum, sidewalls, tip, alar lobules, and soft triangles (Fig 6). Incisions that avoid transecting the esthetic subunits give better cosmetic outcomes. Also, incisions placed at the interface of subunits give better cosmesis due to being hidden by the normal contours of the surface. Placement of the incision at the intersection of dorsal and sidewall subunits of the nose takes advantage of all these principles. The standard lateral rhinotomy incision disregards these principles, transecting the nasal and midfacial subunits of the face. The “V” at the medial canthal region will also minimize the scar retraction and avoid puckering and webbing in this area. The modified incision is with more sharp angulations and corners than the classical one. Accurate alignment of these angles and corners at the closure helps to achieve a superior cosmetic outcome. In conclusion, modified lateral rhinotomy incision through the facial esthetic subunits also has sound anatomical basis, and, hence, creates a better esthetic outcome.
MODIFIED LATERAL RHINOTOMY APPROACH
References 1. Mertz JS, Pearson BW, Kern EB: Lateral rhinotomy: Indications, technique, and review of 226 patients. Arch Otolaryngol 109: 235, 1983 2. Bernard PJ, Biller HF, Lawson WL, et al: Complications following lateral rhinotomy: Review of 148 patients. Ann Otol Rhinol Laryngol 98:684, 1989 3. Weisman R: Lateral rhinotomy and medial maxillectomy. Otolaryngol Clin North Am 28:1145, 1995 4. Delank KW, Franzen W, Huttenbrink B, et al: Long-term results of lateral rhinotomy with medial maxillo-ethmoidectomy. Laryngorhinootologie 73:270, 1994 5. Bernard PJ, Biller HF, Lawson W, et al: Complications following rhinotomy: Review of 148 patients. Ann Otol Rhinol Laryngol 98:684, 1989 6. Shah JP, Patel SG: Head and Neck Surgery and Oncology (3rd ed) Philadelphia, Mosby Ltd, 2003 7. Hussain A, Hulmi OJ, Murray DP: Lateral rhinotomy through nasal aesthetic subunits. Improved cosmetic outcome. J Laryngol Otol 116:703, 2002 8. Hoeyberghs Jl, Desta K, Matthews RN: The lost muscles of the nose. Aesthetic Plast Surg 20:165, 1996 9. Russell T, Woodburne AM: Essential Human Anatomy (6th ed). New York, Oxford University Press, 1978, p 198 10. Gray’s Anatomy: The Anatomical Basis of Medicine and Surgery (39th ed). Edinburgh, Churchill-Livingstone, 2004 11. Burget GC, Menick FJ: The subunit principle in nasal reconstruction. Plast Reconstr Surg 76:239, 1985
Esthetic and Anatomic Basis of Modified Lateral Rhinotomy Approach Krishnakumar Thankappan, MBBS, MS, DNB,* Rajeev Sharan, MBBS, MS,† Subramania Iyer, Mch, FRCS,‡ and Moni Abraham Kuriakose, MD, FRCS, FDSRCS, FFDRCS§ Lateral rhinotomy is an established approach to the midfacial skeleton.1-3 The standard incision for lateral rhinotomy is placed in the nasofacial groove (Fig 1). This is not without complications.4,5 Several modifications of the incision have been proposed to improve the esthetic results.6,7 We describe the esthetic and anatomic basis for this modified incision and analyze the esthetic outcome of the technique.
corners are accurately aligned at the time of the closure. This is a retrospective review of all patients who have undergone the modified lateral rhinotomy approach during a period of 36 months from March 2004 to February 2007. This approach was used for maxillectomy and craniofacial resections. In craniofacial resections this was used as the transfacial incision for medial maxillotomy to access the nasoethmoid tumors. During the study period 22 patients underwent this procedure. The minimum follow-up was a period of 6 months. Esthetic outcome was evaluated by reviewing the medical records, patient photographs (Figs 3, 4), and by clinical examination at follow-up. The presence of any cosmetic problems like hypertrophic scar, alar blunting, ectropion, telecanthus, or lower lid edema was noted.
Patients and Methods The modified lateral rhinotomy incision (Fig 2) consists of making a vertical incision between the dorsal and lateral esthetic nasal subunits. The incision is extended along the lateral alar groove to the floor of the nose and then if lip split is required it exits the nasal cavity, leaving a triangular notch in the floor of the nasal cavity. A “V” is incorporated in the incision at the midpoint between the dorsum and the medial canthus. The flap is harvested laterally in the subperiosteal plane. The incision can be extended superiorly or laterally along the subciliary line. The subciliary extension is but rarely indicated. For extension to the medial orbital wall, it is necessary to isolate and detach the medial canthus, which is tagged at the time of incision and later attached to the bone. Upper lip split if necessary is made through the midline. Closure is performed in 2 layers. All the angles and
Results The modified lateral rhinotomy approach was carried out in 9 cases of maxillectomy and 13 cases of craniofacial resections. Table 1 shows the details. The esthetic outcome is listed in Table 2. None of the patients had hypertrophic scar along the incision, alar blunting, or lower lid edema. Two cases where subciliary extension was done had minimal ectropion. One patient of craniofacial resection had telecanthus, but this was due to the detachment of the medial canthus from its bony attachment and not related to the incision. None of the patients complained of an unesthetic scar.
*Fellow in Head and Neck Surgery, Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, India. †Fellow in Head and Neck Surgery, Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, India. ‡Consultant, Head and Neck, and Chief, Department of Plastic and Reconstructive Surgery, and Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, India. §Chairman and Head, Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Kochi, India. Address correspondence and reprint requests to Dr Kuriakose: Head and Neck Surgery, Amrita Institute of Medical Sciences, Elamakkara, Kochi, Kerala 682026, India; e-mail: akuriakose@aims. amrita.edu
Discussion Lateral rhinotomy with its various extensions is widely used to approach the midfacial skeleton and the anterior skull base. The classical lateral rhinotomy approach does not follow the esthetic facial subunit principle as well as it causes the disruption of the musculature around the nose. Although it provides reasonable esthetic outcome the result can be improved significantly by following the esthetic and anatomic principles of midface. Understanding the importance of facial subunits and facial skin creases, a
© 2009 American Association of Oral and Maxillofacial Surgeons
0278-2391/09/6701-0037$34.00/0 doi:10.1016/j.joms.2008.07.012
231
232
MODIFIED LATERAL RHINOTOMY APPROACH
FIGURE 1. Standard lateral rhinotomy incision. Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
modification has been described.6,7 The modification attempts to improve the facial appearance, facial expression, and to make the incision inconspicuous.6 This report critically evaluates the esthetic outcome of this modified approach. The muscles that constitute the soft lateral wall of the nose can be divided into a group of “intrinsic muscles” and extrinsic muscles (Fig 5). The extrinsic
FIGURE 3. Esthetic outcome, patient photograph 1. Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
FIGURE 2. Modified lateral rhinotomy incision. Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
muscles include levator labii superioris alaeque nasi, zygomaticus minor, and orbicularis oris. The intrinsic muscles include the procerus, nasalis, depressor septi, dilator naris anterior, compressor narium minor, and depressor alae nasi. Their common insertion is near the alar base.8 The procerus muscle, having its origin mainly on the bony vault of the nose and inserting in the skin of the forehead region between the eyebrows,9 sometimes has bundles running over the nasalis muscle all the way to the end of the nose.10 This muscle is oriented along the long axis of the dorsum. The levator labii superioris alaeque nasi originates in the glabellar region, runs inferolaterally, and gets inserted near the alar base. The conventional lateral rhinotomy incision cuts through the levator labii superioris alaeque nasi, and this may be one of the reasons for the widening of the scar caused by this incision. The modified incision runs along the procerus muscle lateral to it without transverse cutting of the levator labii superioris alaeque nasi except near its
233
THANKAPPAN ET AL
FIGURE 5. Muscles of the nose. Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
insertion. Scar stretching will be minimal in this situation. The face is made up of various esthetic units, and these units have their subunits. The esthetic subunit principle is being used increasingly in reconstructive facial surgery to achieve better cosmetic outcomes. The nose is 1 of the esthetic units of the face and is FIGURE 4. Esthetic outcome, patient photograph 2. Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
Table 1. PATIENT DETAILS
Facial Incision
Maxillectomy (Number of Patients)
Craniofacial Resection (Number of Patients)
0
6
4
2
2
1
3 9
4 13
Lateral rhinotomy Weber-Ferguson (lateral rhinotomy with lip split) Weber-Ferguson with Lynch extension Weber-Ferguson with subciliary extension Total
Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
Table 2. ESTHETIC PROBLEMS
Esthetic Problem
Number of Patients
Hypertrophic scar Alar blunting Ectropion Telecanthus Lower lid edema
0 0 2 1 0
Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
FIGURE 6. Facial esthetic subunits. Thankappan et al. Modified Lateral Rhinotomy Approach. J Oral Maxillofac Surg 2009.
234 made up of smaller subunits of slightly convex and concave surfaces separated by shallow valleys and ridges.11 These subunits are the dorsum, sidewalls, tip, alar lobules, and soft triangles (Fig 6). Incisions that avoid transecting the esthetic subunits give better cosmetic outcomes. Also, incisions placed at the interface of subunits give better cosmesis due to being hidden by the normal contours of the surface. Placement of the incision at the intersection of dorsal and sidewall subunits of the nose takes advantage of all these principles. The standard lateral rhinotomy incision disregards these principles, transecting the nasal and midfacial subunits of the face. The “V” at the medial canthal region will also minimize the scar retraction and avoid puckering and webbing in this area. The modified incision is with more sharp angulations and corners than the classical one. Accurate alignment of these angles and corners at the closure helps to achieve a superior cosmetic outcome. In conclusion, modified lateral rhinotomy incision through the facial esthetic subunits also has sound anatomical basis, and, hence, creates a better esthetic outcome.
MODIFIED LATERAL RHINOTOMY APPROACH
References 1. Mertz JS, Pearson BW, Kern EB: Lateral rhinotomy: Indications, technique, and review of 226 patients. Arch Otolaryngol 109: 235, 1983 2. Bernard PJ, Biller HF, Lawson WL, et al: Complications following lateral rhinotomy: Review of 148 patients. Ann Otol Rhinol Laryngol 98:684, 1989 3. Weisman R: Lateral rhinotomy and medial maxillectomy. Otolaryngol Clin North Am 28:1145, 1995 4. Delank KW, Franzen W, Huttenbrink B, et al: Long-term results of lateral rhinotomy with medial maxillo-ethmoidectomy. Laryngorhinootologie 73:270, 1994 5. Bernard PJ, Biller HF, Lawson W, et al: Complications following rhinotomy: Review of 148 patients. Ann Otol Rhinol Laryngol 98:684, 1989 6. Shah JP, Patel SG: Head and Neck Surgery and Oncology (3rd ed) Philadelphia, Mosby Ltd, 2003 7. Hussain A, Hulmi OJ, Murray DP: Lateral rhinotomy through nasal aesthetic subunits. Improved cosmetic outcome. J Laryngol Otol 116:703, 2002 8. Hoeyberghs Jl, Desta K, Matthews RN: The lost muscles of the nose. Aesthetic Plast Surg 20:165, 1996 9. Russell T, Woodburne AM: Essential Human Anatomy (6th ed). New York, Oxford University Press, 1978, p 198 10. Gray’s Anatomy: The Anatomical Basis of Medicine and Surgery (39th ed). Edinburgh, Churchill-Livingstone, 2004 11. Burget GC, Menick FJ: The subunit principle in nasal reconstruction. Plast Reconstr Surg 76:239, 1985