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Nasal Deformities Involving the Bony and Cartilaginous Framework
CLINICS ON OTHER SUBJECTS NASAL DEFORMITIES INVOLVING THE BONY AND CARTILAGINOUS FRAMEWORK JOHN
B.
ERICH
Deformities of the bony and cartilaginous framework of the nose more often are congenital than acquired. In either case, rhinoplastic operations intended to correct such defects are performed as a rule purely for esthetic reasons. The surgeon who alters the structural arrangement of the nasal bones or cartilages by adjusting, shifting, removing or adding tissues is attempting to improve the appearance of the nose rather than its functions. In some cases in which the external disfigurement is of traumatic origin, it may be associated with fracture dislocations of the nasal septum; the resultant displacement of the septum may interfere with proper drainage of normal secretions and may disturb the physiologic functions of the nasal cavities by changing the natural air currents through the nose. However, with but few exceptions, which will be mentioned later, the surgical repair of septal deflections aimed at improving the functions of the nose is a problem separate from plastic operations intended to alter the existing configuration of the nasal framework. Some physicians still seem prejudiced against so-called cosmetic nasal operations and are reluctant to discuss them with patients requesting information. However, in recent years the psychologic benefits derived from these surgical procedures have been completely substantiated, and there no longer is any need for citing cases to justify them. I shall merely add here that on completion of a successful rhinoplastic operation, to observe the extreme satisfaction and consequent personality changes of some patients who were self-conscious and sensitive about their deformity is a very agreeable experience. This does not imply, of course, that all patients who request a plastic operation because of nasal defects are embarrassed or overly conscious about their disfigurement. The success of rhinoplasty cannot be measured by the surgeon's degree of satisfaction with the outcome of the operation, because the patient may have his own ideas as to what type of nose has pleasing proportions or at least is esthetically acceptable. The success of such an operation is entirely a question of whether or not the patient is pleased with the postoperative result. I believe the success of these surgical procedures is based on three factors, the second and third of which have not received adequate emphasis in the literature. The three factors, which are further elaborated in the following pages, are: (1) skill on the part of the surgeon in rhinoplastic technics; (2) conferences with the patient which refrain from promising any specific postoperative result and (3) proper selection of patients for rhinoplastic operation. 1119
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SKILL OF THE SURGEON
Skill in executing the technical aspects of rhinoplasty is of prime importance in attaining a successful result. Such skill is acquired through thorough training in the fundamental principles of these operations, through appreciation of the anatomic proportions which are desirable in each case, and finally through the experience that comes only by repetition of these surgical technics. Some articles in the literature tend to give the impression that photographs, plaster casts of the face, profilometers for measuring nasal angles and mathematical formulas will practically assure a perfect result in every case. But as was pointed out by Safian,4. 5 nothing is farther from the truth. I do not wish to minimize the importance of photographs and casts, which are essential as records. Every plastic surgeon has encountered the patient who after rhinoplasty is of the opinion that little was accomplished by the operation but soon changes his mind on being shown photographs or casts made before the operation. However, these agents do not augment the surgeon's ability to perform a satisfactory nasal operation. Anatomic structures become distorted by the infiltration or procaine hydrochloride and by the elevation of the skin over the nose so that measurements intended to guide the surgeon in removing parts of the bony and cartilaginous framework no longer are entirely accurate. Moreover, the nose is not a solid, nonelastic object like wood which can be cut and joined together with great accuracy; on the contrary, the adjustment of nasal tissues according to predetermined measurements does not lead necessarily to the desired result because factors other than the amount of tissue removed influence the ultimate shape of the nose. Consequently, a successful result if based not on mathematics, but on the surgeon's experience and ability to know, during the course of the operation, when the nasal tissues have been sufficiently modified to produce the desired effect. PREOPERATIVE CONFERENCE WITH THE PATIENT
Too often the discussion of a nasal plastic operation between surgeon and patient will lead the latter to anticipate a specific type of postoperative result. For instance, the patient may be permitted to choose from stock photographs the type of nose which is most appealing to him and then is encouraged to assume that his nose can be modified to similar proporions, or an attempt is made to outline on a photograph of the patient the changes in nasal contour that an operation can be expected to accomplish. In reality, such precise results are rarely achieved. A patient undergoing rhinoplasty under these circumstances cannot be entirely satisfied with a result which does not· meet his expectations. After a rhinoplastic operation, every patient examines his nose critically and is displeased if the contour does not resemble that which was proposed and promised. At the Clinic, we simply tell a patient who is to have a rhinoplasty that the appearance of his nose should be
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improved but confess that we cannot predetermine its exact contour. Furthermore, he is told that a nose, no matter how perfectly modified during an operation, may unavoidably undergo some distortion during the healing period, and that scar tissue may change the shape of the nose further during the months to follow. If flaws do develop, it occasionally is necessary to perform a secondary operation. A patient, thus informed of the facts and with no promises as to the outcome of the operation, is not going to expect too much or the impossible; when the job has been completed, it has been my observation that he usually is pleased even though some small imperfections may be present. SELECTION OF PATIENTS
Not every person who is desirous of having the contour of his nose modified is a suitable subject for a nasal plastic operation. Moreover, the size of the nasal defect should not necessarily influence the surgeon's willingness to perform rhinoplasty; from the patient's point of view, his deformity always is conspicuous even though not large and always is of much consequence. The Ideal Patient. I believe that the ideal person for rhinoplasty is one who· has no preconceived ideas about what alterations in nasal configuration a plastic operation should accomplish; he merely has a nasal defect about which he mayor may not be sensitive and which he would like to have corrected. He leaves it to the discretion of the surgeon to ascertain what changes should be made and realizes that the final result is not necessarily going to be perfect. Such an individual practically always is pleased and appreciative of whatever improvements can be made in the conformation of his nose. Generally Unacceptable Patients. In contrast to the ideal patient is the person who has mental or emotional peculiarities which make him unacceptable as a candidate for rhinoplastic operation. The latter type of individual nearly always is dissatisfied with the end result of a nasal operation, not only because it fails to solve his problems, but because it may actually add to his difficulties. He is one of a rather large group of patients on whom a plastic surgeon generally would refuse to operate. I would like to discuss this group in more detail; its members may be divided as follows: The Psychopathic Person Who Has No Significant Nasal Defect but Who Possesses All Sorts of Peculiar Conceptions Concerning an Imaginary Deformity of the Nose. It is surprising how many individuals in this category will seek the services of a plastic surgeon for correction of their delusional disfigurement. What far-reaching results some of them expect from a rhinoplastic operation is fantastic to say the least. Recently, an obviously psychotic, but very pleasant and earnest, patient consulted me about his nose. He had no nasal defect but believed that rhinoplasty would produce a "drawing down" of his lower eyelids, which would allow him to raise his head higher while working as a typesetter; this, in
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turn, would cure his backache, exhaustion and increasing distinterest in his work and in his music. Surprisingly to him, he had found no surgeon who was willing to undertake a plastic operation on his nose . . The Psychopathic Individuals Who Have a Ridiculous Notion Concerning Defect of The Nose. Among such persons are those with a paranoid complex who think that everyone is talking and laughing about their noses. In cases such as this the difficulties which a surgeon would encounter after rhinoplasty are countless and need no elaboration. It is· particularly distressing, however, for the unsuspecting surgeon to go ahead with rhinoplasty on a person with an undiagnosed psychosis who seems entirely normal before operation but after operation reveals unmistakable evidence of his distorted mind and often is absurdly displeased with a really satisfactory operative result. The Individual Who Though Mentally Sound Has a Deepseated Inferiority Complex and Attributes All of His or Her Feelings of Inadequacy to Some Deformity of The Nose. Such persons in many instances are of the opinion that rhinoplasty would give them an immediate sense of confidence, so necessary in their various fields of endeavor. Nothing is farther from the truth. The Person With Nasal Deformity Who Wants a Plastic Operation not Because of a Sense of Inferiority but Because He or She Believes That a Handsome or Beautiful Nose Is an Essential Prerequisite to Success in His Chosen Occupation Such as Acting, Selling and the Like. Such an individual may explain to the plastic surgeon that his entire career hinges on the success or failure of the nasal operation. Such notions not only are silly, but no experienced plastic surgeon will have any desire to assume such unreasonable responsibilities. These individuals should not be confused with the fine and well-unified person who does have a conspicuous nasal deformity which does interfere with his calling, but who does not believe that his success in life is dependent altogether on his facial appearance, nor does he expect anything more from rhinoplasty than improvement in the appearance of his nose. Moreover, the results of a rhinoplastic operation on this type of person are gratifying to the patient and surgeon alike. The Person Who Believes That a Nasal Plastic Operation Would so Change His or Her Appearance That The Wife, Husband or Lover Would Take Renewed Interest, Perhaps to the Extent of Rectifying a Broken M.arriage or Love Affair. Rhinoplasties do not solve such problems. The Person Who Has aNasal Defect Who Goes to the Extreme of Having a Plaster Cast Prepared After Which He or She Models in Clay Another Which Suits the Fancy. The clay model is presented by the patient to the plastic surgeon with instructions to modify his nose to correspond. As has been previously mentioned, such requests are impossible to accomplish, and the patient, in turn, never is pleased with the operative result. Consequently, I refuse to operate on a person who prepares casts or models for me to copy during a rhinoplastic operation. The Same may be said for the patient who makes outline drawings of the type of nose he desires.
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The Person Who Presents to the Surgeon a Picture of Some Person He or She Admires, and Expresses the Desire to Have the Nose Fashioned to Resemble That in the Picture. Not only is it impossible to make one nose entirely similar to an:other, but many such an individual goes through mental fantasies imagining that rhinoplasty will modify his whole face as well as his nose to resemble the person he regards with approval. In every instance if such a person is operated on, he is deeply disappointed to find that in spite of a good operative result he still looks just like h~mself.
The Individual Who Has Had Previous Rhinoplastic Operations by Other Surgeons and Still Is Dissatisfied With the Appearance of the Nose. Such persons usually are poor subjects for further nasal operations. Seldom are they happy with the result of another rhinoplasty, and their critical complaints are extremely annoying to the surgeon. RHINOPLASTY
As Aufrich 1, 2 and Safian4 , 5 have pointed out many times the fundamental principles of rhinoplastic surgery were primarily devised by Joseph of Berlin. While there have been some refinements and many variations in technic, Joseph's basic methods still are in use. These technics have been outlined and discussed in so many articles that there is no need of presenting a detailed account of them here. At the Clinic for most rhinoplasties we 4ave found it convenient to use general anesthesia for which pentothal sodium and curare are employed as the anesthetic agents and oxygen is administered through an intratracheal tube emerging from the mouth. For hemostasis, however, I employ 0.5 per cent solution of procaine hydrochloride with epinephrine (1 drop to the dram) which is infiltrated subcutaneously along the sides of the nose, and in the nostrils and columella. Packs of 10 per cent cocaine with epinephrine applied within the anterior part of the nasal chambers also are of inestimable value in controlling hemorrhage. Although some surgeons undermine the skin of the nose through an incision in the columella, I usually make an incision in each nostril along the lower border of the upper lateral cartilage (so-called intercartilaginous incision). A bony hump is removed with right and left bayonetshaped saws, and the cartilaginous part of the hump is cut off with a blunt knife which is inserted under the dissociated bony hump and drawn downward. The latter maneuver for removing the cartilaginous portion of the hump is difficult for the beginner in rhinoplastic surgery and improper execution of this maneuver is the cause of many postoperative imperfections. Regardless of how small the nasal hump may be, its removal calls for fracturing of the nasal bones to narrow the bridge; otherwise, the dorsum of the nose will appear too broad after the hump has been taken away. Detachment of the bony portion of the nose can be accomplished by the use of saws or chisels along the frontal process of the maxilla. I prefer to use a chisel. The lower edge of the frontal process is engaged with it through the intercartilaginous incision. With
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a mallet, the chisel is forced upward almost to the frontal bone. Subsequent lateral (thumb) pressure on each nasal bone is employed to fracture it along its attachment to the frontal bone and force it toward the median line to narrow the nasal bridge. This technic is often referred to as "infracturing" the nasal bones. I have found that Aufricht's method of "outfracturing" is also useful in the prevention of a sharp spicule of bone from remaining attached at the radix nasi. This technic involves the introduction of a chisel between the nasal bone and septum. A few taps of the mallet will send the chisel through the radix nasi, after which the nasal bone can be moved (fractured) outward; finally, lateral pressure will force the nasal bones inward with ease. In many instances
Fig. 290. Nasal deformity. a, Before operation. b, After removal of the hump, narrowing of the nasal bridge, elevation and narrowing of the nasal tip.
after the removal of a hump, the nose will appear too long and should be shortened by removing a triangular segment of the lower anterior part of the nasal septum. The removal of a nasal hUmp which is confined essentially to the bony part of the nose is comparatively easy to accomplish and obtain a satisfactory result (fig. 290), but the reduction to agreeable proportions of "a large rounded hump which involves the entire dorsum often is rather difficult (fig. 291). Although a nasal hump may be rather insignificant, it is surprising what a difference its removal will effect in the patient's facial appearance. Following the removal of a hump, I believe there is often a tendency to elevate the tip of the nose too high. The general features of each pa-
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Fig. 291. Nasal deformity. a, Before operation. b, After removal of the hump, narrowing of the nasal bridge, elevation and narrowing of the nasal tip.
Fig. 292. Nasal deformity. a, Before operation. b, After removal of the hump, narrowing of the nasal bridge, elevation and narrowing of the nasal tip.
tient should govern the degree of elevation that is attempted. The. nasal tip of a woman of small build who has a rounded face as in figure'
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292, can be elevated much higher with pleasing results than that of the tall woman shown in figure 293 could be. Furthermore, the tip of a woman's nose usually can be elevated to a higher degree than that of a man's nOE. In
some cases, the most obvious part of a nasal deformity is a drooping tip or a long nose which should be shortened by elevating the tip. Elevation of the nasal tip by removing a triangular segment of tissue from the lower anterior part of the septum not only improves the patient's appearance from the profile view but also from the direct front view as well (figs. 291 and 295).
Fig. 293. Nasal deformity. a, Before operation. b, After removal of the hump, .narrowing of the nasal bridge and elevation of the nasal tip.
The tips of the noses of many individuals are somewhat rounded or bulbous; it requires not only elevation but narrowing both in a horizontal and in a vertical direction. This is accomplished by excising through each nostril a segment of the lower lateral cartilages in a vertical direction close to the septum and also excising a portion of the upper border of the lower lateral cartilages (fig. 296). Some plastic surgeons do not attempt to change the contour of the lower lateral cartilages, but I think that the appearance of a bulbous nasal tip can be greatly improved when the lower lateral cartilages are reduced in size at operation (fig. 297). Irregular deflections of the nose to one or the other side are not infrequently encountered as a result of traumatic injuries. If the irregularity is confined to the bony bridge and is not associated with any particular
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Fig. 294. Nasal deformity with conspicuous drooping tip. a and c, Before operation. band d, After removal of the hump, and marked elevation and narrowing of the tip.
displacement of the nasal septum, the deformity usually is not difficult to repair by fracturing the nasal bones as previously described and molding them into correct alignment. Mter the nasal bones are retained
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correction of the deformity becomes a difficult problem. Only in those cases in which a septal deflection is associated with external deflection and deformity of the nose do I .consider nasal plastic operation combined
Fig. 296. Shaded area shows the location for removal of tissue from the lower lateral cartilages to narrow the nasal tip in a horizontal and a vertical direction. The cartilages are removed from within the nostril. By excising the portion next to the septum, the remaining part of each lower lateral cartilage is eventually drawn inward by scar tissue to narrow the tip horizontally. The cartilage removed from the upper border of the lower lateral cartilage narrows the tip in a vertical direction.
Fig. 297. Nasal deformity with a bulbous tip. a, Broad and drooping nasal tip . before operation. b, After small hump was removed, the bridge was narrowed and the tip was elevated and markedly narrowed.
with submucous resection of the septum to be advisable. When the septal deflection is not associated with external deformity, I believe that resection of the septum should be performed first while the plastic
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operation is deferred for three or more weeks. In correcting a deformity of the nose caused by traumatic deflection and displacement of the nasal bones, lateral cartilages and septum, I have had better results by following the technic devised by Dr. V. H. Kazanjian of Boston than from other methods (figs. 298, 299 and 300). This technic (fig. 301) consists in submucous resection of the septum in which a segment of septal cartilage is left intact beneath the nasal bridge and above the columella (fig. 301, a). Immediately after the resection of the septum, a plastic operation is performed in which the hump, if present, is removed, the nasal bones are fractured to narrow
Fig. 298. Nasal deformity showing marked deflection of the nasal bones and septum to the left. a, Before operation. b, After deformity was corrected by the technic shown in figure 301.
the bridge and the nasal tip is elevated and perhaps narrowed horizontally and vertically. Next, a chisel is used to separate the spinous process from the maxilla (fig. 301, a), and a small knife is used to detach the upper lateral cartilages and what remains of the septum from the lower border of the nasal bones (fig. 301, b). Except for mucosal attachments, this procedure completely detaches the lateral cartilages and remnants of the septum from the rest of the nose so that they can be placed in any desired position. These cartilages are immobilized in correct alignment by a silk suture passed horizontally through the lower part of the nose and attached to the forehead by adhesive tape (fig. 301, c); in addition, further immobilization is obtained by means of the usual external metal splint. This technic which was demonstrated to me
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Fig. 299. Marked deflection of the nasal bones and septum to the left. a, Before operation. b, After deformity had been corrected by the technic shown in figure 301.
Fig. 300. Marked deflection of the nasal bones and septum to the right. a, Before operation. b, After deformity had been corrected by the technic shown in figure 301.
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by Dr. Kazanjian has given me the most satisfactory results in the type of nasal deformity under discussion. Depressed defects (fig. 302), or so-called saddle-back deformities of the nose, require the transplantation of tissue or the insertion of some foreign material to build up the contour of the nasal bridge to more nearly normal proportions. Some surgeons prefer to use ivory or plastic or metallic substances for this purpose, but in our experience at the Clinic foreign materials never have been satisfactory nasal implants. As a matter of fact, most of them produce some inflammatory reaction after a few months and must be removed. The two tissues which are adaptable for transplantation to the nose are cartilage and bone. I
a
"
c
Fig. 301. Kazanjian's method of straightening the external nose due to deflection of the septum. a, Submucus resection of the cartilaginous part of the septum is done, leaving a segment of septal cartilage intact beneath the nasal bridge and above the columella. A chisel is used to separate the spinous process from the maxilla. b, A small knife detaches the upper lateral cartilage and remnant of the septum from the lower border of the nasal bones. c, The lateral cartilages and remnants of the septum are immobilized by a silk suture passed through the cartilaginous part of the nose and attached to the forehead by adhesive tape.
think that cartilage is the most satisfactory tissue since it will withstand infections that no bone graft would tolerate. If a nasal deformity can be completely corrected merely by the insertion of a transplant through an incision at the lower border of the nose, bone can be employed satisfactorily for this purpose. However, as is usually the case, additional procedures besides the mere insertion of an implant are required to correct the nasal deformity. For instance, the nasal bones often must be fractured to narrow the bridge, or the tip of the nose must be elevated and narrowed surgically. These operative technics leave a subcutaneous wound open to the nasal cavities and consequently to infection. It is believed at the Clinic, therefore, that cartilage is the preferable tissue to employ for transplantation to the nose.
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Of inestimable value is the discovery made in recent years that cartilage can be successfully transplanted from one individual to another and that it can be preserved for an indefinite period by freezing or by immersion in aqueous antiseptic solutions maintained at icebox temperatures. These facts permit utilization of costal cartilage obtained under sterile 'conditions at necropsy. As is well known, preserved cartilage when cut retains its shape because it has undergone a spontaneous process of fixation which has destroyed its elasticity. In spite of the fact that cartilage obtained at necropsy has been employed for nasal implants with much success, it has been my observation that cartilage immersed
Fig. 302. Traumatic saddle-back deformity of the nose. a, Before operation. b, After correction of deformity by autogenous implant of cartilage.
in aqueous antiseptic solutions for a long period is much more likely to be absorbed than is fresh autogenous cartilage. Fresh cartilage which has been frozen is more likely to remain intact after transplantation to the nose than is cartilage immersed in antiseptic solutions, but frozen cartilage again I believe has more of a tendency to absorb than fresh cartilage transplanted from the patient's rib directly to the nose. Consequently, at the Clinic the use of fresh autogenous cartilage grafts is preferred. The one great disadvantage to the use of fresh cartilage transplants is their tendency to undergo distortion by warping, which is most objectionable. However, Dr. G. B. New and I found that the physical nature of fresh cartilage can be rapidly altered by heating and then cooling; this process prevents any inclination of the cartilage graft
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to become distorted after being inserted into the nose. Mter a segment of cartilage has been obtained from the patient's rib, it is introduced into a sterile test tube containing a weak aqueous antiseptic solution. The tube then is placed in a beaker of water which is allowed to boil for ten minutes. When the cartilage is removed from the test tu~e, it is immersed, as a final step, in cold sterile physiologic solution of sodium chloride for at least ten or fifteen minutes. Heating fresh cartilage brings about quick fixation. However, cartilage subjected to heating will undergo on cooling a certain amount of warping. Consequently, it is of the utmost importance that heated cartilage be allowed to cool before it is cut to the desired shape. To obtain costal cartilage for transplanation to the nose, an oblique incision in the skin is made over the right side of the chest. This incision extends from the center of the sternum just above the xiphoid process to the lower border of the thoracic cage in the region of the right midclavicular line. The underlying muscles are cut across to expose the cartilaginous portion of the right sixth and seventh ribs. In the majority of instances, the cartilage of the seventh rib is the least difficult to procure; and it supplies an amount of tissue which is adequate for any nasal implant. The full thickness of the rib is also taken, and it is removed subperichondrially. The segment of cartilage thus removed is heated and cooled as previously described. It is then ready for cutting to the desired shape. Unused pieces of cartilage are not discarded but are frozen in a deep-freeze unit and can be used later on for deformities in other patients. Before undertaking the transplantation of costal cartilage to correct a depressed defect of the nose, it is essential to make lead patterns· of the nasal defect to furnish the surgeon with specific measurements when cutting and shaping the implant. Two such patterns are necessary: one represents the length and width of the desired implant, and one, the outline of the defect from the lateral aspect. The piece of cartilage is cut to the desired shape by means of a scalpel. The lower end of the implant should be tapered to fit into the linear depression between the two lower lateral cartilages of the tip of the nose. Furthermore, the undersurface of the graft should be cut in a concave fashion which is helpful in seating the graft over the nasal bridge and in preserving the desired shape of the implant (fig. 303). To prepare the nose for reception of the cartilage implant, an incision is made in the skin along the lower border of the nostrils (fig. 303). Through this incision the skin over the entire nose is undermined with dissecting scissors or a double-edged knife, and freed from the underlying tissues. This leaves a subcutaneous pocket over the nasal bridge into which the cartilage implant is inserted. It is helpful to undermine the periosteum over the nasal bones so that the upper end of the graft can be inserted between the nasal bones and their periosteal covering; this aids in retaining the implant in proper position. Following these preparations, the implant is inserted through the skin incision. Finally,
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the line of incision is sutured. An external metal splint is applied to prevent formation of hematoma and to maintain the implant in proper position; this is held in place with adhesive tape. If the nasal depression involves only the cartilaginous part of the bridge of the nose, a portion of the bony bridge above should be removed with saws or a chisel. This permits the use of a cartilage implant extending from the nasal tip almost to the glabella (fig. 304). Such a transplant produces a much better cosmetic effect than a small implant applied to the lower half of the nasal bridge.
Co,Ttila.ge
a
b
Fig. 303. a, The incision at the lower border of the nostrils through which cartilage implant is inserted. Lower lateral cartilages have been sutured together to prevent the cartilage implant from slipping down in between them. b, Cartilage implant being inserted.
In individuals, only a little normal tissue holds together the two lower lateral cartilages of the nasal tip in the median line. If such is the case, it is well to separate these cartilages and suture them together with fine plain catgut stitches as is illustrated in figure 303, a. This prevents the lower end of the cartilage implant from slipping between the two lower lateral cartilages and thus producing a depression of the middle third of the nose. It has been my experience that these lower lateral cartilages must be sutured together in practically all cases. This is the reason why I prefer to insert a cartilage implant through an incision at the lower border of the nose which permits exposure of the lower lateral cartilages so that they can be sutured together. The act of inserting a cartilage implant through an intercartilaginous incision in the nostril will not permit one to suture the lower lateral cartilages together. In many instances, the nasal defect requires narrowing of the nasal tip in a horizontal direction. I believe that when a cartilage implant is to be employed, the lower lateral cartilages should not be narrowed by ex-
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cising a segment of the cartilage through the nostril (fig. 296). Instead, I excise a portion of the medial crus of each lower lateral cartilage next to the median line. When the remaining part of these cartilages are sutured together in the midline, the tip of the nose automatically tends to be brought forward, is narrowed and becomes more pointed. I believe that this technic produces a more satisfactory result than the usual method of narrowing the nasal tip from within the nostril.
Fig. 304. Old traumatic deformity of the nose with a depression of the cartilaginous portion of the bridge. a, Before operation. b, After operation. Lower lateral cartilages were separated from each other along the median line and a small portion was excised from each medial crus; the tip was brought forward and narrowed by suturing the cartilages together in the midline. A portion of the bony bridge of the nose was removed with saws so that a cartilage implant could be inserted from the tip of the nose to the lower edge of the frontal bone.
Occasionally, the tip of the nose lacks sufficient cartilaginous support to hold the lower end of the cartilage graft forward in proper position. Many men, under these circumstances, will use a large bone graft (sometimes called "keel" graft) which extends down the dorsum of the nose and bends around into the columella. Other surgeons employ, instead, a columellar post of bone or cartilage to hold up the implant forming the nasal bridge. Such a post is inserted into a surgically prepared tract in the columella and is seated over the spinous process of the maxilla. Above, this post supports the lower tip of the nasal implant. I have always had the impression that the large bone grafts just described or cartilage grafts held up with a columellar post often give the external nose a sort of artificial appearance. Many of these noses do not have a
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perfectly natural appearance but look as though they have had a plastic operation. In my experience, the cartilage implants which produce the most nearly normal appearing noses are those in which I have not used a columellar post. I have found that if the lower lateral cartilages are separated in the median line and then are sutured tightly together that, in most instances, they have sufficient body to stay forward in proper position and also to support the cartilage graft over the nasal bridge (fig. 304). By this technic, I have rarely found it necessary to use "keel" grafts or columellar cartilaginous posts in those cases in which the tip
Fig. 305. Severe traumatic depression defect of the nose. a, Before operation. b, After insertion of a large cartilage implant through an incision at the lower border of the nose.
of the nose seemed to lack sufficient cartilaginous support to hold the lower end of the cartilage graft forward in correct position. I believe that cartilage or bone implants frequently are made too large. A slight residual depression of the nasal bridge resulting from a small implant has a more natural appearance (fig. 305) than an elevated bridge due to a graft of large dimensions. In the latter situation, the nose often has an artificial appearance. In conclusion I would like to add that severe depression defects of the nose, as in figure 306, cannot be built up to normal contour all in one operation. Instead, they are better elevated in stages using successive cartilage implants, one on top of the other. If an attempt were made to correct the deformity in one sitting, the overlying skin would be so
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Fig. 306. Severe depression defect of the bridge of the nose. band c, Before operation. b and d, After insertion of three cartilage implants. These grafts were inserted through an incision at the lower border of the nose in successive stages at intervals of three months.
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-tense that it would be likely to slough. However, if the nasal bridge is elevated in stages at intervals of three to six months, the skin will stretch sufficiently to allow complete repair of the nasal deformity. REFERENCES 1. Aufricht, G.: A Few Hints and Surgical Details in Rhinoplasty. Laryngoscope. 53:317-335 (May) 1943. 2. Aufricht, Gustave: Dental Moulding Compound Cast and Adhesive Strapping in Rhinoplastic Surgical Procedures. Arch. Otolaryng. 32:333--338 (Aug.) 1940. 3. New, G. B. and Erich, J. B.: A Method to Prevent Fresh Costal Cartilage Grafts From Warping. Am. J. Surg. 54:435-438 (Nov.) 1941. 4. Safian, Joseph: Corrective Rhinoplastic Surgery. New York, Paul B. Hoeber, Inc., 1935, 218 pp. 5. Safian, Joseph: A Critical Review of Recent Literature on Rhinoplasty. Plast. & Reconstruct. Surg. 2:463-473 (Sept.) 1947. RELEVANT ARTICLES NOT REFERRED TO IN TEXT
1. Barsky, A. J.: Plastic Surgery. Philadelphia, W. B. Saunders Company, 1938, pp. 145-150. 2. Cohen, Samuel: Role of the Septum in Surgery of the Nasal Contour. Arch' Otolaryng. 30:12-20 (July) 1939. 3. Cohen, Samuel: Plastic Surgery of the Nose. Laryngoscope. 51:363-377 (Apr.) 1941. 4. McDowell, Frank and Brown, J. B.: A Review of Reconstructive Surgery of the Face. Laryngoscope. 50:1117-1138 (Dec.) 1940. 5. Maliniac, J. W.: Rhinoplasty and Restoration of Facial Contour; With Special Reference to Trauma. Philadelphia, F. A. Davis Company, 1947, pp. 228-240. 6. Sheehan, J. E.: A Manual of Reparative Plastic Surgery. New York, Paul B. Hoeber, Inc., 1938, pp. 159-190. 7. Straatsma, C. R.: Some Problems in Nasal Plastic Surgery. Laryngoscope. 50:1092-1099 (Nov.) 1940.
B.
ERICH
Deformities of the bony and cartilaginous framework of the nose more often are congenital than acquired. In either case, rhinoplastic operations intended to correct such defects are performed as a rule purely for esthetic reasons. The surgeon who alters the structural arrangement of the nasal bones or cartilages by adjusting, shifting, removing or adding tissues is attempting to improve the appearance of the nose rather than its functions. In some cases in which the external disfigurement is of traumatic origin, it may be associated with fracture dislocations of the nasal septum; the resultant displacement of the septum may interfere with proper drainage of normal secretions and may disturb the physiologic functions of the nasal cavities by changing the natural air currents through the nose. However, with but few exceptions, which will be mentioned later, the surgical repair of septal deflections aimed at improving the functions of the nose is a problem separate from plastic operations intended to alter the existing configuration of the nasal framework. Some physicians still seem prejudiced against so-called cosmetic nasal operations and are reluctant to discuss them with patients requesting information. However, in recent years the psychologic benefits derived from these surgical procedures have been completely substantiated, and there no longer is any need for citing cases to justify them. I shall merely add here that on completion of a successful rhinoplastic operation, to observe the extreme satisfaction and consequent personality changes of some patients who were self-conscious and sensitive about their deformity is a very agreeable experience. This does not imply, of course, that all patients who request a plastic operation because of nasal defects are embarrassed or overly conscious about their disfigurement. The success of rhinoplasty cannot be measured by the surgeon's degree of satisfaction with the outcome of the operation, because the patient may have his own ideas as to what type of nose has pleasing proportions or at least is esthetically acceptable. The success of such an operation is entirely a question of whether or not the patient is pleased with the postoperative result. I believe the success of these surgical procedures is based on three factors, the second and third of which have not received adequate emphasis in the literature. The three factors, which are further elaborated in the following pages, are: (1) skill on the part of the surgeon in rhinoplastic technics; (2) conferences with the patient which refrain from promising any specific postoperative result and (3) proper selection of patients for rhinoplastic operation. 1119
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SKILL OF THE SURGEON
Skill in executing the technical aspects of rhinoplasty is of prime importance in attaining a successful result. Such skill is acquired through thorough training in the fundamental principles of these operations, through appreciation of the anatomic proportions which are desirable in each case, and finally through the experience that comes only by repetition of these surgical technics. Some articles in the literature tend to give the impression that photographs, plaster casts of the face, profilometers for measuring nasal angles and mathematical formulas will practically assure a perfect result in every case. But as was pointed out by Safian,4. 5 nothing is farther from the truth. I do not wish to minimize the importance of photographs and casts, which are essential as records. Every plastic surgeon has encountered the patient who after rhinoplasty is of the opinion that little was accomplished by the operation but soon changes his mind on being shown photographs or casts made before the operation. However, these agents do not augment the surgeon's ability to perform a satisfactory nasal operation. Anatomic structures become distorted by the infiltration or procaine hydrochloride and by the elevation of the skin over the nose so that measurements intended to guide the surgeon in removing parts of the bony and cartilaginous framework no longer are entirely accurate. Moreover, the nose is not a solid, nonelastic object like wood which can be cut and joined together with great accuracy; on the contrary, the adjustment of nasal tissues according to predetermined measurements does not lead necessarily to the desired result because factors other than the amount of tissue removed influence the ultimate shape of the nose. Consequently, a successful result if based not on mathematics, but on the surgeon's experience and ability to know, during the course of the operation, when the nasal tissues have been sufficiently modified to produce the desired effect. PREOPERATIVE CONFERENCE WITH THE PATIENT
Too often the discussion of a nasal plastic operation between surgeon and patient will lead the latter to anticipate a specific type of postoperative result. For instance, the patient may be permitted to choose from stock photographs the type of nose which is most appealing to him and then is encouraged to assume that his nose can be modified to similar proporions, or an attempt is made to outline on a photograph of the patient the changes in nasal contour that an operation can be expected to accomplish. In reality, such precise results are rarely achieved. A patient undergoing rhinoplasty under these circumstances cannot be entirely satisfied with a result which does not· meet his expectations. After a rhinoplastic operation, every patient examines his nose critically and is displeased if the contour does not resemble that which was proposed and promised. At the Clinic, we simply tell a patient who is to have a rhinoplasty that the appearance of his nose should be
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improved but confess that we cannot predetermine its exact contour. Furthermore, he is told that a nose, no matter how perfectly modified during an operation, may unavoidably undergo some distortion during the healing period, and that scar tissue may change the shape of the nose further during the months to follow. If flaws do develop, it occasionally is necessary to perform a secondary operation. A patient, thus informed of the facts and with no promises as to the outcome of the operation, is not going to expect too much or the impossible; when the job has been completed, it has been my observation that he usually is pleased even though some small imperfections may be present. SELECTION OF PATIENTS
Not every person who is desirous of having the contour of his nose modified is a suitable subject for a nasal plastic operation. Moreover, the size of the nasal defect should not necessarily influence the surgeon's willingness to perform rhinoplasty; from the patient's point of view, his deformity always is conspicuous even though not large and always is of much consequence. The Ideal Patient. I believe that the ideal person for rhinoplasty is one who· has no preconceived ideas about what alterations in nasal configuration a plastic operation should accomplish; he merely has a nasal defect about which he mayor may not be sensitive and which he would like to have corrected. He leaves it to the discretion of the surgeon to ascertain what changes should be made and realizes that the final result is not necessarily going to be perfect. Such an individual practically always is pleased and appreciative of whatever improvements can be made in the conformation of his nose. Generally Unacceptable Patients. In contrast to the ideal patient is the person who has mental or emotional peculiarities which make him unacceptable as a candidate for rhinoplastic operation. The latter type of individual nearly always is dissatisfied with the end result of a nasal operation, not only because it fails to solve his problems, but because it may actually add to his difficulties. He is one of a rather large group of patients on whom a plastic surgeon generally would refuse to operate. I would like to discuss this group in more detail; its members may be divided as follows: The Psychopathic Person Who Has No Significant Nasal Defect but Who Possesses All Sorts of Peculiar Conceptions Concerning an Imaginary Deformity of the Nose. It is surprising how many individuals in this category will seek the services of a plastic surgeon for correction of their delusional disfigurement. What far-reaching results some of them expect from a rhinoplastic operation is fantastic to say the least. Recently, an obviously psychotic, but very pleasant and earnest, patient consulted me about his nose. He had no nasal defect but believed that rhinoplasty would produce a "drawing down" of his lower eyelids, which would allow him to raise his head higher while working as a typesetter; this, in
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JOHN B. ERICH
turn, would cure his backache, exhaustion and increasing distinterest in his work and in his music. Surprisingly to him, he had found no surgeon who was willing to undertake a plastic operation on his nose . . The Psychopathic Individuals Who Have a Ridiculous Notion Concerning Defect of The Nose. Among such persons are those with a paranoid complex who think that everyone is talking and laughing about their noses. In cases such as this the difficulties which a surgeon would encounter after rhinoplasty are countless and need no elaboration. It is· particularly distressing, however, for the unsuspecting surgeon to go ahead with rhinoplasty on a person with an undiagnosed psychosis who seems entirely normal before operation but after operation reveals unmistakable evidence of his distorted mind and often is absurdly displeased with a really satisfactory operative result. The Individual Who Though Mentally Sound Has a Deepseated Inferiority Complex and Attributes All of His or Her Feelings of Inadequacy to Some Deformity of The Nose. Such persons in many instances are of the opinion that rhinoplasty would give them an immediate sense of confidence, so necessary in their various fields of endeavor. Nothing is farther from the truth. The Person With Nasal Deformity Who Wants a Plastic Operation not Because of a Sense of Inferiority but Because He or She Believes That a Handsome or Beautiful Nose Is an Essential Prerequisite to Success in His Chosen Occupation Such as Acting, Selling and the Like. Such an individual may explain to the plastic surgeon that his entire career hinges on the success or failure of the nasal operation. Such notions not only are silly, but no experienced plastic surgeon will have any desire to assume such unreasonable responsibilities. These individuals should not be confused with the fine and well-unified person who does have a conspicuous nasal deformity which does interfere with his calling, but who does not believe that his success in life is dependent altogether on his facial appearance, nor does he expect anything more from rhinoplasty than improvement in the appearance of his nose. Moreover, the results of a rhinoplastic operation on this type of person are gratifying to the patient and surgeon alike. The Person Who Believes That a Nasal Plastic Operation Would so Change His or Her Appearance That The Wife, Husband or Lover Would Take Renewed Interest, Perhaps to the Extent of Rectifying a Broken M.arriage or Love Affair. Rhinoplasties do not solve such problems. The Person Who Has aNasal Defect Who Goes to the Extreme of Having a Plaster Cast Prepared After Which He or She Models in Clay Another Which Suits the Fancy. The clay model is presented by the patient to the plastic surgeon with instructions to modify his nose to correspond. As has been previously mentioned, such requests are impossible to accomplish, and the patient, in turn, never is pleased with the operative result. Consequently, I refuse to operate on a person who prepares casts or models for me to copy during a rhinoplastic operation. The Same may be said for the patient who makes outline drawings of the type of nose he desires.
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The Person Who Presents to the Surgeon a Picture of Some Person He or She Admires, and Expresses the Desire to Have the Nose Fashioned to Resemble That in the Picture. Not only is it impossible to make one nose entirely similar to an:other, but many such an individual goes through mental fantasies imagining that rhinoplasty will modify his whole face as well as his nose to resemble the person he regards with approval. In every instance if such a person is operated on, he is deeply disappointed to find that in spite of a good operative result he still looks just like h~mself.
The Individual Who Has Had Previous Rhinoplastic Operations by Other Surgeons and Still Is Dissatisfied With the Appearance of the Nose. Such persons usually are poor subjects for further nasal operations. Seldom are they happy with the result of another rhinoplasty, and their critical complaints are extremely annoying to the surgeon. RHINOPLASTY
As Aufrich 1, 2 and Safian4 , 5 have pointed out many times the fundamental principles of rhinoplastic surgery were primarily devised by Joseph of Berlin. While there have been some refinements and many variations in technic, Joseph's basic methods still are in use. These technics have been outlined and discussed in so many articles that there is no need of presenting a detailed account of them here. At the Clinic for most rhinoplasties we 4ave found it convenient to use general anesthesia for which pentothal sodium and curare are employed as the anesthetic agents and oxygen is administered through an intratracheal tube emerging from the mouth. For hemostasis, however, I employ 0.5 per cent solution of procaine hydrochloride with epinephrine (1 drop to the dram) which is infiltrated subcutaneously along the sides of the nose, and in the nostrils and columella. Packs of 10 per cent cocaine with epinephrine applied within the anterior part of the nasal chambers also are of inestimable value in controlling hemorrhage. Although some surgeons undermine the skin of the nose through an incision in the columella, I usually make an incision in each nostril along the lower border of the upper lateral cartilage (so-called intercartilaginous incision). A bony hump is removed with right and left bayonetshaped saws, and the cartilaginous part of the hump is cut off with a blunt knife which is inserted under the dissociated bony hump and drawn downward. The latter maneuver for removing the cartilaginous portion of the hump is difficult for the beginner in rhinoplastic surgery and improper execution of this maneuver is the cause of many postoperative imperfections. Regardless of how small the nasal hump may be, its removal calls for fracturing of the nasal bones to narrow the bridge; otherwise, the dorsum of the nose will appear too broad after the hump has been taken away. Detachment of the bony portion of the nose can be accomplished by the use of saws or chisels along the frontal process of the maxilla. I prefer to use a chisel. The lower edge of the frontal process is engaged with it through the intercartilaginous incision. With
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JOHN B. ERICH
a mallet, the chisel is forced upward almost to the frontal bone. Subsequent lateral (thumb) pressure on each nasal bone is employed to fracture it along its attachment to the frontal bone and force it toward the median line to narrow the nasal bridge. This technic is often referred to as "infracturing" the nasal bones. I have found that Aufricht's method of "outfracturing" is also useful in the prevention of a sharp spicule of bone from remaining attached at the radix nasi. This technic involves the introduction of a chisel between the nasal bone and septum. A few taps of the mallet will send the chisel through the radix nasi, after which the nasal bone can be moved (fractured) outward; finally, lateral pressure will force the nasal bones inward with ease. In many instances
Fig. 290. Nasal deformity. a, Before operation. b, After removal of the hump, narrowing of the nasal bridge, elevation and narrowing of the nasal tip.
after the removal of a hump, the nose will appear too long and should be shortened by removing a triangular segment of the lower anterior part of the nasal septum. The removal of a nasal hUmp which is confined essentially to the bony part of the nose is comparatively easy to accomplish and obtain a satisfactory result (fig. 290), but the reduction to agreeable proportions of "a large rounded hump which involves the entire dorsum often is rather difficult (fig. 291). Although a nasal hump may be rather insignificant, it is surprising what a difference its removal will effect in the patient's facial appearance. Following the removal of a hump, I believe there is often a tendency to elevate the tip of the nose too high. The general features of each pa-
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Fig. 291. Nasal deformity. a, Before operation. b, After removal of the hump, narrowing of the nasal bridge, elevation and narrowing of the nasal tip.
Fig. 292. Nasal deformity. a, Before operation. b, After removal of the hump, narrowing of the nasal bridge, elevation and narrowing of the nasal tip.
tient should govern the degree of elevation that is attempted. The. nasal tip of a woman of small build who has a rounded face as in figure'
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JOHN B. ERICH
292, can be elevated much higher with pleasing results than that of the tall woman shown in figure 293 could be. Furthermore, the tip of a woman's nose usually can be elevated to a higher degree than that of a man's nOE. In
some cases, the most obvious part of a nasal deformity is a drooping tip or a long nose which should be shortened by elevating the tip. Elevation of the nasal tip by removing a triangular segment of tissue from the lower anterior part of the septum not only improves the patient's appearance from the profile view but also from the direct front view as well (figs. 291 and 295).
Fig. 293. Nasal deformity. a, Before operation. b, After removal of the hump, .narrowing of the nasal bridge and elevation of the nasal tip.
The tips of the noses of many individuals are somewhat rounded or bulbous; it requires not only elevation but narrowing both in a horizontal and in a vertical direction. This is accomplished by excising through each nostril a segment of the lower lateral cartilages in a vertical direction close to the septum and also excising a portion of the upper border of the lower lateral cartilages (fig. 296). Some plastic surgeons do not attempt to change the contour of the lower lateral cartilages, but I think that the appearance of a bulbous nasal tip can be greatly improved when the lower lateral cartilages are reduced in size at operation (fig. 297). Irregular deflections of the nose to one or the other side are not infrequently encountered as a result of traumatic injuries. If the irregularity is confined to the bony bridge and is not associated with any particular
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Fig. 294. Nasal deformity with conspicuous drooping tip. a and c, Before operation. band d, After removal of the hump, and marked elevation and narrowing of the tip.
displacement of the nasal septum, the deformity usually is not difficult to repair by fracturing the nasal bones as previously described and molding them into correct alignment. Mter the nasal bones are retained
1 2
J
B.
I
1 plin, ,h n.
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correction of the deformity becomes a difficult problem. Only in those cases in which a septal deflection is associated with external deflection and deformity of the nose do I .consider nasal plastic operation combined
Fig. 296. Shaded area shows the location for removal of tissue from the lower lateral cartilages to narrow the nasal tip in a horizontal and a vertical direction. The cartilages are removed from within the nostril. By excising the portion next to the septum, the remaining part of each lower lateral cartilage is eventually drawn inward by scar tissue to narrow the tip horizontally. The cartilage removed from the upper border of the lower lateral cartilage narrows the tip in a vertical direction.
Fig. 297. Nasal deformity with a bulbous tip. a, Broad and drooping nasal tip . before operation. b, After small hump was removed, the bridge was narrowed and the tip was elevated and markedly narrowed.
with submucous resection of the septum to be advisable. When the septal deflection is not associated with external deformity, I believe that resection of the septum should be performed first while the plastic
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JOHN B. ERICH
operation is deferred for three or more weeks. In correcting a deformity of the nose caused by traumatic deflection and displacement of the nasal bones, lateral cartilages and septum, I have had better results by following the technic devised by Dr. V. H. Kazanjian of Boston than from other methods (figs. 298, 299 and 300). This technic (fig. 301) consists in submucous resection of the septum in which a segment of septal cartilage is left intact beneath the nasal bridge and above the columella (fig. 301, a). Immediately after the resection of the septum, a plastic operation is performed in which the hump, if present, is removed, the nasal bones are fractured to narrow
Fig. 298. Nasal deformity showing marked deflection of the nasal bones and septum to the left. a, Before operation. b, After deformity was corrected by the technic shown in figure 301.
the bridge and the nasal tip is elevated and perhaps narrowed horizontally and vertically. Next, a chisel is used to separate the spinous process from the maxilla (fig. 301, a), and a small knife is used to detach the upper lateral cartilages and what remains of the septum from the lower border of the nasal bones (fig. 301, b). Except for mucosal attachments, this procedure completely detaches the lateral cartilages and remnants of the septum from the rest of the nose so that they can be placed in any desired position. These cartilages are immobilized in correct alignment by a silk suture passed horizontally through the lower part of the nose and attached to the forehead by adhesive tape (fig. 301, c); in addition, further immobilization is obtained by means of the usual external metal splint. This technic which was demonstrated to me
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Fig. 299. Marked deflection of the nasal bones and septum to the left. a, Before operation. b, After deformity had been corrected by the technic shown in figure 301.
Fig. 300. Marked deflection of the nasal bones and septum to the right. a, Before operation. b, After deformity had been corrected by the technic shown in figure 301.
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JOHN B. ERICH
by Dr. Kazanjian has given me the most satisfactory results in the type of nasal deformity under discussion. Depressed defects (fig. 302), or so-called saddle-back deformities of the nose, require the transplantation of tissue or the insertion of some foreign material to build up the contour of the nasal bridge to more nearly normal proportions. Some surgeons prefer to use ivory or plastic or metallic substances for this purpose, but in our experience at the Clinic foreign materials never have been satisfactory nasal implants. As a matter of fact, most of them produce some inflammatory reaction after a few months and must be removed. The two tissues which are adaptable for transplantation to the nose are cartilage and bone. I
a
"
c
Fig. 301. Kazanjian's method of straightening the external nose due to deflection of the septum. a, Submucus resection of the cartilaginous part of the septum is done, leaving a segment of septal cartilage intact beneath the nasal bridge and above the columella. A chisel is used to separate the spinous process from the maxilla. b, A small knife detaches the upper lateral cartilage and remnant of the septum from the lower border of the nasal bones. c, The lateral cartilages and remnants of the septum are immobilized by a silk suture passed through the cartilaginous part of the nose and attached to the forehead by adhesive tape.
think that cartilage is the most satisfactory tissue since it will withstand infections that no bone graft would tolerate. If a nasal deformity can be completely corrected merely by the insertion of a transplant through an incision at the lower border of the nose, bone can be employed satisfactorily for this purpose. However, as is usually the case, additional procedures besides the mere insertion of an implant are required to correct the nasal deformity. For instance, the nasal bones often must be fractured to narrow the bridge, or the tip of the nose must be elevated and narrowed surgically. These operative technics leave a subcutaneous wound open to the nasal cavities and consequently to infection. It is believed at the Clinic, therefore, that cartilage is the preferable tissue to employ for transplantation to the nose.
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Of inestimable value is the discovery made in recent years that cartilage can be successfully transplanted from one individual to another and that it can be preserved for an indefinite period by freezing or by immersion in aqueous antiseptic solutions maintained at icebox temperatures. These facts permit utilization of costal cartilage obtained under sterile 'conditions at necropsy. As is well known, preserved cartilage when cut retains its shape because it has undergone a spontaneous process of fixation which has destroyed its elasticity. In spite of the fact that cartilage obtained at necropsy has been employed for nasal implants with much success, it has been my observation that cartilage immersed
Fig. 302. Traumatic saddle-back deformity of the nose. a, Before operation. b, After correction of deformity by autogenous implant of cartilage.
in aqueous antiseptic solutions for a long period is much more likely to be absorbed than is fresh autogenous cartilage. Fresh cartilage which has been frozen is more likely to remain intact after transplantation to the nose than is cartilage immersed in antiseptic solutions, but frozen cartilage again I believe has more of a tendency to absorb than fresh cartilage transplanted from the patient's rib directly to the nose. Consequently, at the Clinic the use of fresh autogenous cartilage grafts is preferred. The one great disadvantage to the use of fresh cartilage transplants is their tendency to undergo distortion by warping, which is most objectionable. However, Dr. G. B. New and I found that the physical nature of fresh cartilage can be rapidly altered by heating and then cooling; this process prevents any inclination of the cartilage graft
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JOHN B. ERICH
to become distorted after being inserted into the nose. Mter a segment of cartilage has been obtained from the patient's rib, it is introduced into a sterile test tube containing a weak aqueous antiseptic solution. The tube then is placed in a beaker of water which is allowed to boil for ten minutes. When the cartilage is removed from the test tu~e, it is immersed, as a final step, in cold sterile physiologic solution of sodium chloride for at least ten or fifteen minutes. Heating fresh cartilage brings about quick fixation. However, cartilage subjected to heating will undergo on cooling a certain amount of warping. Consequently, it is of the utmost importance that heated cartilage be allowed to cool before it is cut to the desired shape. To obtain costal cartilage for transplanation to the nose, an oblique incision in the skin is made over the right side of the chest. This incision extends from the center of the sternum just above the xiphoid process to the lower border of the thoracic cage in the region of the right midclavicular line. The underlying muscles are cut across to expose the cartilaginous portion of the right sixth and seventh ribs. In the majority of instances, the cartilage of the seventh rib is the least difficult to procure; and it supplies an amount of tissue which is adequate for any nasal implant. The full thickness of the rib is also taken, and it is removed subperichondrially. The segment of cartilage thus removed is heated and cooled as previously described. It is then ready for cutting to the desired shape. Unused pieces of cartilage are not discarded but are frozen in a deep-freeze unit and can be used later on for deformities in other patients. Before undertaking the transplantation of costal cartilage to correct a depressed defect of the nose, it is essential to make lead patterns· of the nasal defect to furnish the surgeon with specific measurements when cutting and shaping the implant. Two such patterns are necessary: one represents the length and width of the desired implant, and one, the outline of the defect from the lateral aspect. The piece of cartilage is cut to the desired shape by means of a scalpel. The lower end of the implant should be tapered to fit into the linear depression between the two lower lateral cartilages of the tip of the nose. Furthermore, the undersurface of the graft should be cut in a concave fashion which is helpful in seating the graft over the nasal bridge and in preserving the desired shape of the implant (fig. 303). To prepare the nose for reception of the cartilage implant, an incision is made in the skin along the lower border of the nostrils (fig. 303). Through this incision the skin over the entire nose is undermined with dissecting scissors or a double-edged knife, and freed from the underlying tissues. This leaves a subcutaneous pocket over the nasal bridge into which the cartilage implant is inserted. It is helpful to undermine the periosteum over the nasal bones so that the upper end of the graft can be inserted between the nasal bones and their periosteal covering; this aids in retaining the implant in proper position. Following these preparations, the implant is inserted through the skin incision. Finally,
1135
NASAL DEFORMITIES
the line of incision is sutured. An external metal splint is applied to prevent formation of hematoma and to maintain the implant in proper position; this is held in place with adhesive tape. If the nasal depression involves only the cartilaginous part of the bridge of the nose, a portion of the bony bridge above should be removed with saws or a chisel. This permits the use of a cartilage implant extending from the nasal tip almost to the glabella (fig. 304). Such a transplant produces a much better cosmetic effect than a small implant applied to the lower half of the nasal bridge.
Co,Ttila.ge
a
b
Fig. 303. a, The incision at the lower border of the nostrils through which cartilage implant is inserted. Lower lateral cartilages have been sutured together to prevent the cartilage implant from slipping down in between them. b, Cartilage implant being inserted.
In individuals, only a little normal tissue holds together the two lower lateral cartilages of the nasal tip in the median line. If such is the case, it is well to separate these cartilages and suture them together with fine plain catgut stitches as is illustrated in figure 303, a. This prevents the lower end of the cartilage implant from slipping between the two lower lateral cartilages and thus producing a depression of the middle third of the nose. It has been my experience that these lower lateral cartilages must be sutured together in practically all cases. This is the reason why I prefer to insert a cartilage implant through an incision at the lower border of the nose which permits exposure of the lower lateral cartilages so that they can be sutured together. The act of inserting a cartilage implant through an intercartilaginous incision in the nostril will not permit one to suture the lower lateral cartilages together. In many instances, the nasal defect requires narrowing of the nasal tip in a horizontal direction. I believe that when a cartilage implant is to be employed, the lower lateral cartilages should not be narrowed by ex-
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JOHN B. ERICH
cising a segment of the cartilage through the nostril (fig. 296). Instead, I excise a portion of the medial crus of each lower lateral cartilage next to the median line. When the remaining part of these cartilages are sutured together in the midline, the tip of the nose automatically tends to be brought forward, is narrowed and becomes more pointed. I believe that this technic produces a more satisfactory result than the usual method of narrowing the nasal tip from within the nostril.
Fig. 304. Old traumatic deformity of the nose with a depression of the cartilaginous portion of the bridge. a, Before operation. b, After operation. Lower lateral cartilages were separated from each other along the median line and a small portion was excised from each medial crus; the tip was brought forward and narrowed by suturing the cartilages together in the midline. A portion of the bony bridge of the nose was removed with saws so that a cartilage implant could be inserted from the tip of the nose to the lower edge of the frontal bone.
Occasionally, the tip of the nose lacks sufficient cartilaginous support to hold the lower end of the cartilage graft forward in proper position. Many men, under these circumstances, will use a large bone graft (sometimes called "keel" graft) which extends down the dorsum of the nose and bends around into the columella. Other surgeons employ, instead, a columellar post of bone or cartilage to hold up the implant forming the nasal bridge. Such a post is inserted into a surgically prepared tract in the columella and is seated over the spinous process of the maxilla. Above, this post supports the lower tip of the nasal implant. I have always had the impression that the large bone grafts just described or cartilage grafts held up with a columellar post often give the external nose a sort of artificial appearance. Many of these noses do not have a
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perfectly natural appearance but look as though they have had a plastic operation. In my experience, the cartilage implants which produce the most nearly normal appearing noses are those in which I have not used a columellar post. I have found that if the lower lateral cartilages are separated in the median line and then are sutured tightly together that, in most instances, they have sufficient body to stay forward in proper position and also to support the cartilage graft over the nasal bridge (fig. 304). By this technic, I have rarely found it necessary to use "keel" grafts or columellar cartilaginous posts in those cases in which the tip
Fig. 305. Severe traumatic depression defect of the nose. a, Before operation. b, After insertion of a large cartilage implant through an incision at the lower border of the nose.
of the nose seemed to lack sufficient cartilaginous support to hold the lower end of the cartilage graft forward in correct position. I believe that cartilage or bone implants frequently are made too large. A slight residual depression of the nasal bridge resulting from a small implant has a more natural appearance (fig. 305) than an elevated bridge due to a graft of large dimensions. In the latter situation, the nose often has an artificial appearance. In conclusion I would like to add that severe depression defects of the nose, as in figure 306, cannot be built up to normal contour all in one operation. Instead, they are better elevated in stages using successive cartilage implants, one on top of the other. If an attempt were made to correct the deformity in one sitting, the overlying skin would be so
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JOHN B. ERICH
Fig. 306. Severe depression defect of the bridge of the nose. band c, Before operation. b and d, After insertion of three cartilage implants. These grafts were inserted through an incision at the lower border of the nose in successive stages at intervals of three months.
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-tense that it would be likely to slough. However, if the nasal bridge is elevated in stages at intervals of three to six months, the skin will stretch sufficiently to allow complete repair of the nasal deformity. REFERENCES 1. Aufricht, G.: A Few Hints and Surgical Details in Rhinoplasty. Laryngoscope. 53:317-335 (May) 1943. 2. Aufricht, Gustave: Dental Moulding Compound Cast and Adhesive Strapping in Rhinoplastic Surgical Procedures. Arch. Otolaryng. 32:333--338 (Aug.) 1940. 3. New, G. B. and Erich, J. B.: A Method to Prevent Fresh Costal Cartilage Grafts From Warping. Am. J. Surg. 54:435-438 (Nov.) 1941. 4. Safian, Joseph: Corrective Rhinoplastic Surgery. New York, Paul B. Hoeber, Inc., 1935, 218 pp. 5. Safian, Joseph: A Critical Review of Recent Literature on Rhinoplasty. Plast. & Reconstruct. Surg. 2:463-473 (Sept.) 1947. RELEVANT ARTICLES NOT REFERRED TO IN TEXT
1. Barsky, A. J.: Plastic Surgery. Philadelphia, W. B. Saunders Company, 1938, pp. 145-150. 2. Cohen, Samuel: Role of the Septum in Surgery of the Nasal Contour. Arch' Otolaryng. 30:12-20 (July) 1939. 3. Cohen, Samuel: Plastic Surgery of the Nose. Laryngoscope. 51:363-377 (Apr.) 1941. 4. McDowell, Frank and Brown, J. B.: A Review of Reconstructive Surgery of the Face. Laryngoscope. 50:1117-1138 (Dec.) 1940. 5. Maliniac, J. W.: Rhinoplasty and Restoration of Facial Contour; With Special Reference to Trauma. Philadelphia, F. A. Davis Company, 1947, pp. 228-240. 6. Sheehan, J. E.: A Manual of Reparative Plastic Surgery. New York, Paul B. Hoeber, Inc., 1938, pp. 159-190. 7. Straatsma, C. R.: Some Problems in Nasal Plastic Surgery. Laryngoscope. 50:1092-1099 (Nov.) 1940.