- Email: [email protected]
Surgical Treatment of the Middle Nasal Vault
S u r g i c a l Tre a t m e n t o f t h e Middle Nasal Vault Amir Allak, MD, MBA, Stephen S. Park, MD* KEYWORDS Middle nasal vault Internal nasal valve Nasal obstruction Valve collapse Upper lateral cartilage Spreader graft
KEY POINTS
INTRODUCTION
ANATOMY
Successful rhinoplasty is contingent on the appropriate evaluation of matching anatomic deformities to surgical strategies. The surgeon must understand the structurally sensitive regions of the nose and the implications of surgical alteration to both cosmesis and nasal function. The middle nasal vault is a critical anatomic region for the esthetics of the middle third of the nose as well as for maintaining nasal airflow. In patients evaluated for secondary rhinoplasty, middle third visual deformity and obstruction account for 2 of the 3 most common findings.1 In both primary and revision rhinoplasty, special consideration must be dedicated to addressing deformities and preserving supporting structures of the middle vault because this is an important point in the prevention of postoperative complications.
The middle nasal vault is difficult to understand because of its complex 3-dimensional anatomy and dynamic alteration with nasal airflow. The middle vault is also referred to as the cartilaginous vault and comprises cutaneous tissue, a musculoaponeurotic layer, upper lateral cartilages (ULC), dorsal septum, and intranasal mucosa. The cutaneous tissue is often the thinnest over the middle third of the nasal envelope. The superficial musculoaponeurotic system (SMAS) over the nose contains the transverse nasal and levator alaeque nasi and has fascial insertions inferiorly along the anterior septum, the lower lateral cartilages (LLCs), and the columella.2 The paired ULC are deep to the SMAS and anchored superiorly to the undersurface of the nasal bones in the socalled K-area. Inferiorly, they are attached to the
The authors have nothing to disclose. Department of Otolaryngology–Head and Neck Surgery, University of Virginia, PO Box 800713, Charlottesville, VA 22908, USA * Corresponding author. E-mail address: [email protected] Clin Plastic Surg 43 (2016) 85–94 http://dx.doi.org/10.1016/j.cps.2015.09.010 0094-1298/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
The middle nasal vault is a critical region of the esthetics and function of the nose. Internal valve collapse is associated with abnormalities that arises in the middle vault. The thinnest nasal skin is over the middle third, and irregularities are often not well masked. Proper resuspension of the upper lateral cartilages during rhinoplasty will prevent postoperative cosmetic deformities and nasal obstruction. Dorsal hump reduction may unmask underlying middle vault abnormality and should be accompanied by appropriate grafting when indicated.
86
Allak & Park LLCs in the scroll region, and laterally, the soft tissue of the sidewall connects them to the piriform aperture. The ULC medially articulates with the dorsal edge of the cartilaginous septum, where the dorsal septum is often wider, forming a T- or Y-shaped orientation. When progressing toward the caudal aspect of the ULC, the angle between the septum and sidewall becomes more and more acute, narrowing the nasal airway.3 At this level, the reported normal angle in Caucasians is 10 to 20 .4 Intranasal mucosa is fixed to the undersurface of the ULC and is continuous with the septal mucosa. The internal nasal valve is bound by the caudal aspect of the ULC anterolaterally, septum medially, and inferior turbinate posterolaterally (Fig. 1). Because of its low cross-sectional area, nasal airflow is physiologically subject to the highest resistance in this area, as dictated by Poiseuille’s law. When accounting for Bernoulli effect, the high air velocity causes collapse at the internal valve, which can be pathologic if there is a lack of adequate structural support. In fact, approximately 1 in 6 patients with chronic nasal obstruction will
Fig. 1. Cadaveric dissection with blue demarcation of the ULC and LLC. The red oval indicates the area that corresponds with the internal valve in the middle vault.
have collapse of the internal nasal valve.5 When considering that the cross-sectional area of the internal nasal valve decreases by 25% after reduction rhinoplasty, it is not surprising that many patients have postoperative obstruction.6 Therefore, it is essential to address the middle vault effectively to avoid causing iatrogenic weakening of the nasal valve or exacerbating stenosis in patients with unfavorable anatomy.
PREOPERATIVE PLANNING AND PREPARATION Evaluation of the rhinoplasty patient is paramount before any surgical intervention is planned. The surgeon should be thorough in inquiry of desires and expectations of the patient and differentiate functional and cosmetic concerns. The patient should relay which specific esthetic features are bothersome and the anticipated change. Surgery should be avoided if the patient’s expectations are unrealistic or there is any indication of significant psychological abnormality suggesting body dysmorphic disorder. Preoperative photographs should be taken and reviewed with the patient to facilitate discussion and education of the areas of concern. Morphing imaging software can be additionally helpful in demonstrating a reasonable result and if that is an acceptable outcome for the patient. A detailed history should be taken regarding nasal obstruction with laterality, alleviating or exacerbating factors, prior interventions, and any concomitant sinonasal disease. Prior nasal surgery, facial trauma, history of severe diabetes, granulomatous or bleeding/clotting diseases, smoking, and intranasal drug use are also important to document. The surgeon should always inquire regarding anticoagulation use, including supplements that alter the clotting cascade and heavy nonsteroidal anti-inflammatory drug use. In the case of revision surgery, review of prior operative reports is beneficial if records are available. Physical examination should include facial and nasal esthetics as well as a functional analysis. The middle vault correlates externally with the middle third of the nose and is best viewed from the frontal and lateral views. General observation should include patient height, facial proportions, overall skin quality and thickness, scars, and obvious deformities. Special consideration is given to the skin overlying the middle vault because it is often the thinnest of any region of the nose. The frontal view will reveal a narrow or wide middle vault, or asymmetry/deviation of the middle third that could indicate dorsal septal deviation or twisting (Fig. 2). A lack of appropriate shadowing along the dorsum would suggest
Surgical Treatment of the Middle Nasal Vault
Fig. 2. Frontal view displaying a narrow or pinched middle third indicating middle vault abnormality.
underprojection. In patients with prior surgery, the hourglass or inverted V deformity is visible from the frontal view and would create an interruption of the smooth brow-tip line, indicating poor middle vault support. The lateral view shows projection and shape of the middle third. Ideally, the nasal dorsum should be a straight line from the radix to the tip in male patients and in females, a very slight concavity present for the supratip break.7 Overprojection is often a result of a dorsal hump, essentially overdevelopment of the cartilaginous dorsal septum, especially the anterior septal angle (Fig. 3). Tip rotation/projection and radix height should be noted because tip ptosis and a low radix produce a pseudohump (Fig. 4).8 Inadequate chin projection can have a similar effect in creating the illusion of a larger nose. Pollybeak deformity is also apparent on lateral view and refers to the situation when the supratip projects farther than the tip. This can be a result of addressing the bony but underresection of the cartilaginous portion of a dorsal hump and can also be due to fibrous tissue formation at the supratip after cartilaginous dorsal hump and anterior septal angle overresection. Underprojection of the middle third can be a result of prior overaggressive dorsal hump reduction, dorsal cartilage resection during septoplasty, or a septal perforation causing a saddle nose deformity (Fig. 5).
Fig. 3. Lateral view in a patient with dorsal hump and middle third overprojection.
Fig. 4. Lateral view displaying a low radix creating the illusion of a pseudohump. This patient has both a low radix and a true dorsal hump.
87
88
Allak & Park
Fig. 6. Intranasal view of middle vault collapse.
PROCEDURAL APPROACH
Fig. 5. Lateral view in a patient with saddle nose and middle third underprojection.
Although endonasal approaches exist for certain aspects of middle vault surgery, the surgical exposure is best optimized with the external rhinoplasty approach. For the purposes of this article, the open technique is highlighted, as are the areas where an endonasal approach is feasible.
Preparation Palpation of the nose provides adjunctive information to the visual examination, including skin quality, dorsal hump composition, nasal bone length, and lateral nasal wall support. Also, placement of a gloved thumb and second finger on either side of the intranasal dorsal septum can give additive information about intrinsic septal deviation. The functional examination focuses on the intranasal static and dynamic aspects of inspiratory airflow. A static examination should include identification of septal deviation or perforation, ULC collapse, inferior turbinate hypertrophy, as well as any nasal bone or external valve/intervalve abnormality (Fig. 6). While occluding the contralateral naris, the surgeon asks the patient to inhale through the nose with mild force to evaluate for dynamic collapse. Inadequate force may not unmask collapse, whereas an overly forceful inhalation will cause there to be collapse that may not be pathologic. Careful assessment of the true location of obstruction is critical to addressing the correct level of collapse with the appropriate surgical strategy. In lieu of the Cottle maneuver, the surgeon places a small-tipped instrument (eg, cerumen loop) to support specifically the area of objective collapse while the patient repeats the inhalation to assess for subjective improvement.
Patients undergo induction of general anesthesia and endotracheal intubation. The head is placed in a neuro headrest in a neutral position. The endotracheal tube is sewn to the precise midline mentum to facilitate intraoperative visual assessments of symmetry and to avoid pulling the nose to one side. The surgical lights are also placed in the midline so as not to cast asymmetric shadows. Lidocaine 1% with 1:100,000 epinephrine is injected into the nasal soft tissue envelope and septal mucosa with a portion submucosally for hydrodissection. Pledgets soaked in 1% tetracaine/0.05% oxymetazoline are placed in the nasal cavity. Mineral oil/petrolatum ophthalmologic lubricant is placed in the eyes. The face and neck are prepared with Poloxamer 188–containing wash and povidoneiodine 10% solution, and a head wrap is placed with a sterile towel. Appropriate sterile draping is performed.
External Approach An inverted V columellar incision is carried out with a number-15-c blade midway between
Surgical Treatment of the Middle Nasal Vault
the alar base and anterior aspect of the naris, taking care not to injure the medial crura of the LLC. Vertical columellar incisions are performed. While retracting the ala with a skin hook and everting the lateral crus, marginal incisions are performed at the caudal aspect of the lateral crura. The marginal and columellar incisions are joined while maintaining 3-point countertraction, and the nasal envelope is dissected from the LLCs in a submuscular plane. The anterior septal angle is identified, and the submuscular dissection is carried out over the dorsal septum where the ULC and the middle vault are exposed. The dissection plane should be just superficial to the cartilage to ensure adequate thickness of the overlying soft tissue. Standard open septoplasty can be performed at this point for resection of deviated septal elements and cartilage harvest for grafting. If a bony hump is to be reduced, a Joseph periosteal elevator is used to create a subperiosteal pocket. In the case that osteotomies are expected, this dissection should not be carried out laterally to preserve soft tissue support of the nasal bones. At the termination of the case, closure is performed with a single 5-0 polydioxanone (PDS) deep stitch in the midline columella, 6-0 fast absorbing gut interrupted stitches for the skin of the inverted V incision, and 5-0 chromic for marginal incisions when grafts are placed.
Widening of the Narrow Middle Vault Spreader grafts are the mainstay of widening the middle vault. Using septal cartilage either from open septoplasty or via a hemitransfixion incison, unilateral or bilateral grafts are created in a long rectangular shape with beveled ends. These grafts should be 1 to 2 cm in length, 1 to 4 mm in width, and no more than 5 mm in height so as not to impinge on the nasal airway.9 Mucosa is elevated from the dorsal septum and the undersurface of the ULC, wherein the ULC are carefully disarticulated from the dorsal septum with a Freer or Cottle periosteal elevator. The graft or grafts are placed between the anterior aspect of the ULC and the dorsal septum (Fig. 7). These grafts can be held in place with either Brown-Adson forceps or a 27-gauge needle placed through all 3 structures. Several 5-0 nylon sutures are then used to secure the graft in place (Fig. 8). Auto-spreaders, also known as spreader flaps, have become more popular in recent
Fig. 7. Schematic illustration of spreader placement. Note the location between ULC, dorsal septum, and middle vault nasal mucosa.
years. Auto-spreaders entail mucosal elevation as with normal spreader grafts, then use of the medial aspect of the ULC themselves as a spreader; this is accomplished with either complete separation, a partial thickness incision and hinged placement, or folding of the medial aspect of the cartilage without any incisions. Auto-spreaders are secured in the same fashion as standard spreaders.10 Additional cartilage grafts can be also be placed to assist in stiffening the structure of the ULC adjacent to the internal valve to prevent collapse. Conchal cartilage is used with the concave face down, superficial to the caudal aspect of the ULC as a butterfly graft or deep to it as an ULC splay graft. These grafts are suture fixed with a 5-0 PDS or clear nylon and act almost as an implantable breathe-strip.11,12 Flaring sutures are also used to improve the internal valve by increasing the angle of the ULC in relation to the dorsal septum. A 50 clear nylon suture is placed in a vertical mattress fashion across the caudal aspect of the ULC and tied across the nasal dorsum, effectively using it as a fulcrum for flaring of
89
90
Allak & Park
Fig. 9. ULC flaring suture.
Fig. 8. Intraoperative view of bilateral spreader graft inset.
the narrow portion of the valve (Fig. 9). This portion of the cartilage is often difficult to visualize and can be delivered with an intranasal cotton tipped applicator.13 When placed in isolation, it is technically feasible to place spreader grafts with a closed approach after careful elevation of submucosal pockets through an intercartilaginous incision. However, when spreader grafts are often placed along with other interventions, the open approach provides better visualization and ability to suture the grafts to the dorsal septum and to place extended spreader grafts.
Narrowing of the Wide Middle Vault In patients with wide middle vaults, coexisting nasal obstruction is not common, and conservative dorsal width reduction is a feasible option. The so-called reverse spreader technique has been described and can be performed via open or closed approaches (intercartilaginous and partial transfixion incisions). After disarticulation of the ULC from the dorsal septum, a narrow strip of the medial aspect of the ULC is resected. The cross-sectional shape is a
wedge bevel so as to take more of the external redundant ULC and less of the intranasal aspect to prevent valve collapse. The cartilage is then reapproximated with 5-0 Vicryl.14 Often a wide middle vault is accompanied by wide nasal bones, and osteotomies should be performed when indicated.
Dorsal Hump Reduction for Overprojection Submucoperichondrial elevation is carried out between the dorsal septum and intranasal mucosa with a Cottle periosteal elevator. The mucosa is then dissected from the undersurface of the ULC and carried out under the nasal bones, taking care not to disrupt the karea and lose the anchoring point of the ULC. The ULC are disarticulated from the dorsal septum to allow for separate reduction and prevent overresection. In the case of an isolated dorsal hump, the closed approach can be used with an intercartilaginous incision. The cartilaginous hump is then sharply excised with a number 11 or number 15 blade (Fig. 10). This portion is either removed or kept attached to the caudal aspect of the nasal bones for engagement of a Rubin osteotome for bony resection (Figs. 11–13). Care is taken not to disrupt the ULC attachments to the undersurface of the nasal bones.
Surgical Treatment of the Middle Nasal Vault
Fig. 12. Resulting defect after hump reduction. Fig. 10. The cartilaginous portion of the dorsal hump is excised sharply with a number 11 blade.
Alternatively, the cartilaginous portion is removed, and rasps are used to reduce the nasal bones. Coarse rasping should be followed by a fine diamond rasp for contouring of fine irregularities as the nasal skin is thinnest at the rhinion and does not tolerate even subtle deformity. Rasping should be performed at an oblique angle to again avoid loss of ULC attachment and direct trauma to the ULC themselves. In cases of isolated bony hump deformities, powered burrs or rasps can be used with good success and minimal collateral tissue damage when used properly.
Fig. 11. The Rubin osteotome is used to engage and resect the bony portion of the dorsal hump through the cartilaginous incision.
The wound is irrigated to remove bony debris, and the nasal soft tissues are redraped. Firm pressure is applied to the nose with salinesoaked gauze. A moistened fingertip is used to palpate the dorsum for any persistent irregularities. Further resection or rasping should be performed if necessary. Autologous temporalis fascia or crushed cartilage can be placed for further masking of subtle deformity. Spreader grafts can be placed at this point if deemed necessary. ULC are then resuspended to the new dorsal edge of the septum with a 50 clear nylon suture. It should be noted that resection of the dorsal aspect of the septum may unmask a septal deviation, which may cause asymmetry if not addressed before ULC resuspension. If an open roof deformity is created from bony hump resection, lateral osteotomies should
Fig. 13. Excised dorsal hump placed on the nasal envelope.
91
92
Allak & Park be performed to reapproximate the medial aspect of the nasal bones.
Dorsal Augmentation for Underprojection External or endonasal (via intercartilagenous incision) approaches can be used for placement of a dorsal onlay graft for augmentation. Dissection along the dorsum should be limited to the area where the graft is to be placed and should be submuscular. Excessive lateral dissection may lead to graft displacement. A coarse rasp can be used to abrade and prepare the dorsum for optimal biointegration of grafted material. Septal, auricular, or rib cartilage can be used. Costochondral rib graft can be an option in case there is significant dorsal deficit that includes the nasal bones (Fig. 14). In the absence of ideally contoured autograft material, cartilage can be morselized and wrapped in temporalis fascia. If desired, additional fascia or acellular dermis can be overlaid to smooth any irregularities. If autografted material is chosen, appropriate contouring should include a concavity on the deep aspect, smooth convexity on the superficial surface, and slightly tapered cephalic and caudal tips (Fig. 15). This contouring can be performed with cold or powered instrumentation. Once appropriate shape and contour are achieved, the graft is placed into the pocket (Fig. 16) and occasionally secured to the underlying structure with sutures or even percutaneous titanium screws or K-wires. A moldable rigid nasal splint and tape should secure the reconstruction externally to minimize graft movement. Excellent dorsal projection can be achieved with this technique (Fig. 17).
Fig. 14. Costal cartilage carved into a dorsal augmentation graft.
Fig. 15. Carving of the deep surface of the dorsal augmentation graft in a concave fashion for articulation with the nasal dorsum.
Correcting the Deviated/Twisted Middle Vault After disarticulation of the ULC and complete septal mucosal elevation, the septum should be examined for deviation and intrinsic curvature (Fig. 18). If excessive length is observed, a conservative strip of the inferior aspect of the cartilaginous septum can be resected to release it from the floor. Mild higher dorsal deviations can also be addressed with scoring of the concave surface or conservative fullthickness cartilaginous incisions to weaken the structure. If spreader grafts are deemed necessary, a unilateral spreader can be used to straighten the dorsal deviation. Alternatively, variable thickness bilateral spreader grafts can be constructed and placed. For persistent deviations or dorsal septal deflections, an extracorporeal septoplasty can be performed and reimplanted in an orientation providing a midline anchor for the ULC. In addition, the twisted cartilage can be fixed
Fig. 16. Proposed placement of dorsal augmentation graft.
Surgical Treatment of the Middle Nasal Vault Fig. 17. Before and after dorsal augmentation.
to explanted ethmoid bone or a perforated polydioxanone plate (0.15 mm thickness) with 4-0 PDS suture. If ethmoid bone is used, holes can be hand drilled with an 18gauge needle to prevent cracking. In cases when the middle vault is underprojected and there is a recalcitrant dorsal septal deviation, an overlay graft can be placed with the lateral aspects suture fixed to the ULC
with a 5-0 nylon suture so it will also function as an onlay spreader graft. A camouflage graft can be fixed on the overlay to enhance projection and set the dorsum midline.15
POSTPROCEDURAL CARE Cutaneous taping is performed on all patients with 0.5-in paper tape; external splints are applied for osteotomies, and intranasal Doyle splints and intranasal packs are used sparingly. Patients are given prophylactic antibiotics to cover general skin flora and strict activity restrictions until the first postoperative appointment at 1 week. At that time, dressings and splints are removed (as are K-wires or screws for dorsal augmentation). Full activity is resumed at 2 to 4 weeks postoperatively.
POTENTIAL COMPLICATIONS AND MANAGEMENT
Fig. 18. Deviation and curvature of the dorsal septum causing a twisted nose and middle vault collapse.
Low dorsal height and saddle nose Cause: Overresection of dorsal hump Consequence: Cosmetic deformity, may lead to nasal obstruction and static/dynamic valve collapse Treatment: dorsal augmentation Pollybeak and supratip deformity Cause: Blood filling the potential space of the supratip after dorsal hump overresection, which incites an inflammatory reaction and fibrosis obscuring the supratip break.
93
Allak & Park
94
Also caused by cartilaginous underresection and residual anterior septal angle Consequence: Cosmetic deformity Treatment: Initially taping, deep steroid injections as early as 6 to 8 weeks, and revision surgery only after 6 to 12 months. Reresection if anterior septal angle remains Inverted V deformity Cause: Collapse of ULC at internal valve after inadequate resuspension or loss of suspensory support at K-area Consequence: Cosmetic deformity, nasal obstruction Treatment: Resuspension, possible spreader grafts Open roof deformity Cause: Inadequate reapproximation of nasal bones after bony dorsal hump reduction Consequence: Cosmetic deformity Treatment: Lateral osteotomies, possible small dorsal onlay if inadequate bone remains to cover the defect Graft infection Cause: Bacterial colonization and infection of implanted materials Consequence: Delayed healing, graft loss, or need for explant Treatment: Initially antibiotics and local wound care; operative explant for persistent infections and future revision Graft migration (dorsal augmentation) Cause: Inadequate securing of graft to underlying dorsum Consequence: Cosmetic deformity Treatment: Repeat suspension with taping, wires, or screws. May require revision if graft fixes in improper location Nasal valve collapse Cause: Improper ULC suspension, underestimation of graft size, persistent septal deviation Consequence: Nasal obstruction Treatment: May eventually require surgical revision
SUMMARY Understanding the middle nasal vault is important for rhinoplasty surgeons. Given its complex 3dimensional anatomy and vulnerability to esthetic deformity and internal valve collapse, consideration should always be given to the effect that common rhinoplasty maneuvers will have on the middle third of the nose. Identifying and addressing potential pitfalls of the middle vault during
primary rhinoplasty will lead to better outcomes and more satisfied patients.
REFERENCES 1. Yu K, Kim A, Pearlman SJ. Functional and aesthetic concerns of patients seeking revision rhinoplasty. Arch Facial Plast Surg 2010;12:291–7. 2. Saban Y, Amodeo CA, Hammou JC, et al. An anatomical study of the nasal superficial musculoaponeurotic system. Arch Facial Plast Surg 2008; 10(2):109–15. 3. Toriumi DM. Management of the middle nasal vault in rhinoplasty. Op Tech Plast Reconstr Surg 1995; 2(1):16–20. 4. Kasperbauer JL, Kern EB. Nasal valve physiology: implications in nasal surgery. Otolaryngol Clin North Am 1987;20:699–719. 5. Constantian MB. Differing characteristics in 100 consecutive secondary rhinoplasty patients following closed versus open surgical approaches. Plast Reconstr Surg 2002;109(6):2097–111. 6. Grymer LF. Reduction rhinoplasty and nasal patency: change in the cross-sectional area of the nose evaluated by acoustic rhinometry. Laryngoscope 1995;105(4 Pt 1):429–31. 7. Taub PJ, Baker SB. Operative atlas of rhinoplasty. New York: McGraw-Hill, Inc; 2011. 8. Mowlavi A, Meldrum DG, Wilhelmi BJ. Implications for nasal recontouring: nasion position preferences as determined by a survey of white North Americans. Aesthetic Plast Surg 2003;27(6):438–45. 9. Toriumi DM, Johnson CMJ. Open structure rhinoplasty: featured technical points and long-term follow-up. Facial Plast Surg Clin North Am 1993;1: 1–22. 10. Byrd HS, Meade RA, Gonyon DL Jr. Using the autospreader flap in primary rhinoplasty. Plast Reconstr Surg 2007;119(6):1897–902. 11. Clark JM, Cook TA. The ’butterfly’ graft in functional secondary rhinoplasty. Laryngoscope 2002;112: 1917–25. 12. Guyuron B, Michelow BJ, Englebardt C. Upper lateral splay graft. Plast Reconstr Surg 1998; 102(6):2169–77. 13. Park SS. The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg 1998;101:1120–2. 14. Prendiville S, Zimbler MS, Kokoska MS, et al. Middle-vault narrowing in the wide nasal dorsum: the “Reverse Spreader” technique. Arch Facial Plast Surg 2002;4(1):52–5. 15. Murakami C. Nasal valve collapse. Ear Nose Throat J 2004;83:163–4.
KEY POINTS
INTRODUCTION
ANATOMY
Successful rhinoplasty is contingent on the appropriate evaluation of matching anatomic deformities to surgical strategies. The surgeon must understand the structurally sensitive regions of the nose and the implications of surgical alteration to both cosmesis and nasal function. The middle nasal vault is a critical anatomic region for the esthetics of the middle third of the nose as well as for maintaining nasal airflow. In patients evaluated for secondary rhinoplasty, middle third visual deformity and obstruction account for 2 of the 3 most common findings.1 In both primary and revision rhinoplasty, special consideration must be dedicated to addressing deformities and preserving supporting structures of the middle vault because this is an important point in the prevention of postoperative complications.
The middle nasal vault is difficult to understand because of its complex 3-dimensional anatomy and dynamic alteration with nasal airflow. The middle vault is also referred to as the cartilaginous vault and comprises cutaneous tissue, a musculoaponeurotic layer, upper lateral cartilages (ULC), dorsal septum, and intranasal mucosa. The cutaneous tissue is often the thinnest over the middle third of the nasal envelope. The superficial musculoaponeurotic system (SMAS) over the nose contains the transverse nasal and levator alaeque nasi and has fascial insertions inferiorly along the anterior septum, the lower lateral cartilages (LLCs), and the columella.2 The paired ULC are deep to the SMAS and anchored superiorly to the undersurface of the nasal bones in the socalled K-area. Inferiorly, they are attached to the
The authors have nothing to disclose. Department of Otolaryngology–Head and Neck Surgery, University of Virginia, PO Box 800713, Charlottesville, VA 22908, USA * Corresponding author. E-mail address: [email protected] Clin Plastic Surg 43 (2016) 85–94 http://dx.doi.org/10.1016/j.cps.2015.09.010 0094-1298/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
The middle nasal vault is a critical region of the esthetics and function of the nose. Internal valve collapse is associated with abnormalities that arises in the middle vault. The thinnest nasal skin is over the middle third, and irregularities are often not well masked. Proper resuspension of the upper lateral cartilages during rhinoplasty will prevent postoperative cosmetic deformities and nasal obstruction. Dorsal hump reduction may unmask underlying middle vault abnormality and should be accompanied by appropriate grafting when indicated.
86
Allak & Park LLCs in the scroll region, and laterally, the soft tissue of the sidewall connects them to the piriform aperture. The ULC medially articulates with the dorsal edge of the cartilaginous septum, where the dorsal septum is often wider, forming a T- or Y-shaped orientation. When progressing toward the caudal aspect of the ULC, the angle between the septum and sidewall becomes more and more acute, narrowing the nasal airway.3 At this level, the reported normal angle in Caucasians is 10 to 20 .4 Intranasal mucosa is fixed to the undersurface of the ULC and is continuous with the septal mucosa. The internal nasal valve is bound by the caudal aspect of the ULC anterolaterally, septum medially, and inferior turbinate posterolaterally (Fig. 1). Because of its low cross-sectional area, nasal airflow is physiologically subject to the highest resistance in this area, as dictated by Poiseuille’s law. When accounting for Bernoulli effect, the high air velocity causes collapse at the internal valve, which can be pathologic if there is a lack of adequate structural support. In fact, approximately 1 in 6 patients with chronic nasal obstruction will
Fig. 1. Cadaveric dissection with blue demarcation of the ULC and LLC. The red oval indicates the area that corresponds with the internal valve in the middle vault.
have collapse of the internal nasal valve.5 When considering that the cross-sectional area of the internal nasal valve decreases by 25% after reduction rhinoplasty, it is not surprising that many patients have postoperative obstruction.6 Therefore, it is essential to address the middle vault effectively to avoid causing iatrogenic weakening of the nasal valve or exacerbating stenosis in patients with unfavorable anatomy.
PREOPERATIVE PLANNING AND PREPARATION Evaluation of the rhinoplasty patient is paramount before any surgical intervention is planned. The surgeon should be thorough in inquiry of desires and expectations of the patient and differentiate functional and cosmetic concerns. The patient should relay which specific esthetic features are bothersome and the anticipated change. Surgery should be avoided if the patient’s expectations are unrealistic or there is any indication of significant psychological abnormality suggesting body dysmorphic disorder. Preoperative photographs should be taken and reviewed with the patient to facilitate discussion and education of the areas of concern. Morphing imaging software can be additionally helpful in demonstrating a reasonable result and if that is an acceptable outcome for the patient. A detailed history should be taken regarding nasal obstruction with laterality, alleviating or exacerbating factors, prior interventions, and any concomitant sinonasal disease. Prior nasal surgery, facial trauma, history of severe diabetes, granulomatous or bleeding/clotting diseases, smoking, and intranasal drug use are also important to document. The surgeon should always inquire regarding anticoagulation use, including supplements that alter the clotting cascade and heavy nonsteroidal anti-inflammatory drug use. In the case of revision surgery, review of prior operative reports is beneficial if records are available. Physical examination should include facial and nasal esthetics as well as a functional analysis. The middle vault correlates externally with the middle third of the nose and is best viewed from the frontal and lateral views. General observation should include patient height, facial proportions, overall skin quality and thickness, scars, and obvious deformities. Special consideration is given to the skin overlying the middle vault because it is often the thinnest of any region of the nose. The frontal view will reveal a narrow or wide middle vault, or asymmetry/deviation of the middle third that could indicate dorsal septal deviation or twisting (Fig. 2). A lack of appropriate shadowing along the dorsum would suggest
Surgical Treatment of the Middle Nasal Vault
Fig. 2. Frontal view displaying a narrow or pinched middle third indicating middle vault abnormality.
underprojection. In patients with prior surgery, the hourglass or inverted V deformity is visible from the frontal view and would create an interruption of the smooth brow-tip line, indicating poor middle vault support. The lateral view shows projection and shape of the middle third. Ideally, the nasal dorsum should be a straight line from the radix to the tip in male patients and in females, a very slight concavity present for the supratip break.7 Overprojection is often a result of a dorsal hump, essentially overdevelopment of the cartilaginous dorsal septum, especially the anterior septal angle (Fig. 3). Tip rotation/projection and radix height should be noted because tip ptosis and a low radix produce a pseudohump (Fig. 4).8 Inadequate chin projection can have a similar effect in creating the illusion of a larger nose. Pollybeak deformity is also apparent on lateral view and refers to the situation when the supratip projects farther than the tip. This can be a result of addressing the bony but underresection of the cartilaginous portion of a dorsal hump and can also be due to fibrous tissue formation at the supratip after cartilaginous dorsal hump and anterior septal angle overresection. Underprojection of the middle third can be a result of prior overaggressive dorsal hump reduction, dorsal cartilage resection during septoplasty, or a septal perforation causing a saddle nose deformity (Fig. 5).
Fig. 3. Lateral view in a patient with dorsal hump and middle third overprojection.
Fig. 4. Lateral view displaying a low radix creating the illusion of a pseudohump. This patient has both a low radix and a true dorsal hump.
87
88
Allak & Park
Fig. 6. Intranasal view of middle vault collapse.
PROCEDURAL APPROACH
Fig. 5. Lateral view in a patient with saddle nose and middle third underprojection.
Although endonasal approaches exist for certain aspects of middle vault surgery, the surgical exposure is best optimized with the external rhinoplasty approach. For the purposes of this article, the open technique is highlighted, as are the areas where an endonasal approach is feasible.
Preparation Palpation of the nose provides adjunctive information to the visual examination, including skin quality, dorsal hump composition, nasal bone length, and lateral nasal wall support. Also, placement of a gloved thumb and second finger on either side of the intranasal dorsal septum can give additive information about intrinsic septal deviation. The functional examination focuses on the intranasal static and dynamic aspects of inspiratory airflow. A static examination should include identification of septal deviation or perforation, ULC collapse, inferior turbinate hypertrophy, as well as any nasal bone or external valve/intervalve abnormality (Fig. 6). While occluding the contralateral naris, the surgeon asks the patient to inhale through the nose with mild force to evaluate for dynamic collapse. Inadequate force may not unmask collapse, whereas an overly forceful inhalation will cause there to be collapse that may not be pathologic. Careful assessment of the true location of obstruction is critical to addressing the correct level of collapse with the appropriate surgical strategy. In lieu of the Cottle maneuver, the surgeon places a small-tipped instrument (eg, cerumen loop) to support specifically the area of objective collapse while the patient repeats the inhalation to assess for subjective improvement.
Patients undergo induction of general anesthesia and endotracheal intubation. The head is placed in a neuro headrest in a neutral position. The endotracheal tube is sewn to the precise midline mentum to facilitate intraoperative visual assessments of symmetry and to avoid pulling the nose to one side. The surgical lights are also placed in the midline so as not to cast asymmetric shadows. Lidocaine 1% with 1:100,000 epinephrine is injected into the nasal soft tissue envelope and septal mucosa with a portion submucosally for hydrodissection. Pledgets soaked in 1% tetracaine/0.05% oxymetazoline are placed in the nasal cavity. Mineral oil/petrolatum ophthalmologic lubricant is placed in the eyes. The face and neck are prepared with Poloxamer 188–containing wash and povidoneiodine 10% solution, and a head wrap is placed with a sterile towel. Appropriate sterile draping is performed.
External Approach An inverted V columellar incision is carried out with a number-15-c blade midway between
Surgical Treatment of the Middle Nasal Vault
the alar base and anterior aspect of the naris, taking care not to injure the medial crura of the LLC. Vertical columellar incisions are performed. While retracting the ala with a skin hook and everting the lateral crus, marginal incisions are performed at the caudal aspect of the lateral crura. The marginal and columellar incisions are joined while maintaining 3-point countertraction, and the nasal envelope is dissected from the LLCs in a submuscular plane. The anterior septal angle is identified, and the submuscular dissection is carried out over the dorsal septum where the ULC and the middle vault are exposed. The dissection plane should be just superficial to the cartilage to ensure adequate thickness of the overlying soft tissue. Standard open septoplasty can be performed at this point for resection of deviated septal elements and cartilage harvest for grafting. If a bony hump is to be reduced, a Joseph periosteal elevator is used to create a subperiosteal pocket. In the case that osteotomies are expected, this dissection should not be carried out laterally to preserve soft tissue support of the nasal bones. At the termination of the case, closure is performed with a single 5-0 polydioxanone (PDS) deep stitch in the midline columella, 6-0 fast absorbing gut interrupted stitches for the skin of the inverted V incision, and 5-0 chromic for marginal incisions when grafts are placed.
Widening of the Narrow Middle Vault Spreader grafts are the mainstay of widening the middle vault. Using septal cartilage either from open septoplasty or via a hemitransfixion incison, unilateral or bilateral grafts are created in a long rectangular shape with beveled ends. These grafts should be 1 to 2 cm in length, 1 to 4 mm in width, and no more than 5 mm in height so as not to impinge on the nasal airway.9 Mucosa is elevated from the dorsal septum and the undersurface of the ULC, wherein the ULC are carefully disarticulated from the dorsal septum with a Freer or Cottle periosteal elevator. The graft or grafts are placed between the anterior aspect of the ULC and the dorsal septum (Fig. 7). These grafts can be held in place with either Brown-Adson forceps or a 27-gauge needle placed through all 3 structures. Several 5-0 nylon sutures are then used to secure the graft in place (Fig. 8). Auto-spreaders, also known as spreader flaps, have become more popular in recent
Fig. 7. Schematic illustration of spreader placement. Note the location between ULC, dorsal septum, and middle vault nasal mucosa.
years. Auto-spreaders entail mucosal elevation as with normal spreader grafts, then use of the medial aspect of the ULC themselves as a spreader; this is accomplished with either complete separation, a partial thickness incision and hinged placement, or folding of the medial aspect of the cartilage without any incisions. Auto-spreaders are secured in the same fashion as standard spreaders.10 Additional cartilage grafts can be also be placed to assist in stiffening the structure of the ULC adjacent to the internal valve to prevent collapse. Conchal cartilage is used with the concave face down, superficial to the caudal aspect of the ULC as a butterfly graft or deep to it as an ULC splay graft. These grafts are suture fixed with a 5-0 PDS or clear nylon and act almost as an implantable breathe-strip.11,12 Flaring sutures are also used to improve the internal valve by increasing the angle of the ULC in relation to the dorsal septum. A 50 clear nylon suture is placed in a vertical mattress fashion across the caudal aspect of the ULC and tied across the nasal dorsum, effectively using it as a fulcrum for flaring of
89
90
Allak & Park
Fig. 9. ULC flaring suture.
Fig. 8. Intraoperative view of bilateral spreader graft inset.
the narrow portion of the valve (Fig. 9). This portion of the cartilage is often difficult to visualize and can be delivered with an intranasal cotton tipped applicator.13 When placed in isolation, it is technically feasible to place spreader grafts with a closed approach after careful elevation of submucosal pockets through an intercartilaginous incision. However, when spreader grafts are often placed along with other interventions, the open approach provides better visualization and ability to suture the grafts to the dorsal septum and to place extended spreader grafts.
Narrowing of the Wide Middle Vault In patients with wide middle vaults, coexisting nasal obstruction is not common, and conservative dorsal width reduction is a feasible option. The so-called reverse spreader technique has been described and can be performed via open or closed approaches (intercartilaginous and partial transfixion incisions). After disarticulation of the ULC from the dorsal septum, a narrow strip of the medial aspect of the ULC is resected. The cross-sectional shape is a
wedge bevel so as to take more of the external redundant ULC and less of the intranasal aspect to prevent valve collapse. The cartilage is then reapproximated with 5-0 Vicryl.14 Often a wide middle vault is accompanied by wide nasal bones, and osteotomies should be performed when indicated.
Dorsal Hump Reduction for Overprojection Submucoperichondrial elevation is carried out between the dorsal septum and intranasal mucosa with a Cottle periosteal elevator. The mucosa is then dissected from the undersurface of the ULC and carried out under the nasal bones, taking care not to disrupt the karea and lose the anchoring point of the ULC. The ULC are disarticulated from the dorsal septum to allow for separate reduction and prevent overresection. In the case of an isolated dorsal hump, the closed approach can be used with an intercartilaginous incision. The cartilaginous hump is then sharply excised with a number 11 or number 15 blade (Fig. 10). This portion is either removed or kept attached to the caudal aspect of the nasal bones for engagement of a Rubin osteotome for bony resection (Figs. 11–13). Care is taken not to disrupt the ULC attachments to the undersurface of the nasal bones.
Surgical Treatment of the Middle Nasal Vault
Fig. 12. Resulting defect after hump reduction. Fig. 10. The cartilaginous portion of the dorsal hump is excised sharply with a number 11 blade.
Alternatively, the cartilaginous portion is removed, and rasps are used to reduce the nasal bones. Coarse rasping should be followed by a fine diamond rasp for contouring of fine irregularities as the nasal skin is thinnest at the rhinion and does not tolerate even subtle deformity. Rasping should be performed at an oblique angle to again avoid loss of ULC attachment and direct trauma to the ULC themselves. In cases of isolated bony hump deformities, powered burrs or rasps can be used with good success and minimal collateral tissue damage when used properly.
Fig. 11. The Rubin osteotome is used to engage and resect the bony portion of the dorsal hump through the cartilaginous incision.
The wound is irrigated to remove bony debris, and the nasal soft tissues are redraped. Firm pressure is applied to the nose with salinesoaked gauze. A moistened fingertip is used to palpate the dorsum for any persistent irregularities. Further resection or rasping should be performed if necessary. Autologous temporalis fascia or crushed cartilage can be placed for further masking of subtle deformity. Spreader grafts can be placed at this point if deemed necessary. ULC are then resuspended to the new dorsal edge of the septum with a 50 clear nylon suture. It should be noted that resection of the dorsal aspect of the septum may unmask a septal deviation, which may cause asymmetry if not addressed before ULC resuspension. If an open roof deformity is created from bony hump resection, lateral osteotomies should
Fig. 13. Excised dorsal hump placed on the nasal envelope.
91
92
Allak & Park be performed to reapproximate the medial aspect of the nasal bones.
Dorsal Augmentation for Underprojection External or endonasal (via intercartilagenous incision) approaches can be used for placement of a dorsal onlay graft for augmentation. Dissection along the dorsum should be limited to the area where the graft is to be placed and should be submuscular. Excessive lateral dissection may lead to graft displacement. A coarse rasp can be used to abrade and prepare the dorsum for optimal biointegration of grafted material. Septal, auricular, or rib cartilage can be used. Costochondral rib graft can be an option in case there is significant dorsal deficit that includes the nasal bones (Fig. 14). In the absence of ideally contoured autograft material, cartilage can be morselized and wrapped in temporalis fascia. If desired, additional fascia or acellular dermis can be overlaid to smooth any irregularities. If autografted material is chosen, appropriate contouring should include a concavity on the deep aspect, smooth convexity on the superficial surface, and slightly tapered cephalic and caudal tips (Fig. 15). This contouring can be performed with cold or powered instrumentation. Once appropriate shape and contour are achieved, the graft is placed into the pocket (Fig. 16) and occasionally secured to the underlying structure with sutures or even percutaneous titanium screws or K-wires. A moldable rigid nasal splint and tape should secure the reconstruction externally to minimize graft movement. Excellent dorsal projection can be achieved with this technique (Fig. 17).
Fig. 14. Costal cartilage carved into a dorsal augmentation graft.
Fig. 15. Carving of the deep surface of the dorsal augmentation graft in a concave fashion for articulation with the nasal dorsum.
Correcting the Deviated/Twisted Middle Vault After disarticulation of the ULC and complete septal mucosal elevation, the septum should be examined for deviation and intrinsic curvature (Fig. 18). If excessive length is observed, a conservative strip of the inferior aspect of the cartilaginous septum can be resected to release it from the floor. Mild higher dorsal deviations can also be addressed with scoring of the concave surface or conservative fullthickness cartilaginous incisions to weaken the structure. If spreader grafts are deemed necessary, a unilateral spreader can be used to straighten the dorsal deviation. Alternatively, variable thickness bilateral spreader grafts can be constructed and placed. For persistent deviations or dorsal septal deflections, an extracorporeal septoplasty can be performed and reimplanted in an orientation providing a midline anchor for the ULC. In addition, the twisted cartilage can be fixed
Fig. 16. Proposed placement of dorsal augmentation graft.
Surgical Treatment of the Middle Nasal Vault Fig. 17. Before and after dorsal augmentation.
to explanted ethmoid bone or a perforated polydioxanone plate (0.15 mm thickness) with 4-0 PDS suture. If ethmoid bone is used, holes can be hand drilled with an 18gauge needle to prevent cracking. In cases when the middle vault is underprojected and there is a recalcitrant dorsal septal deviation, an overlay graft can be placed with the lateral aspects suture fixed to the ULC
with a 5-0 nylon suture so it will also function as an onlay spreader graft. A camouflage graft can be fixed on the overlay to enhance projection and set the dorsum midline.15
POSTPROCEDURAL CARE Cutaneous taping is performed on all patients with 0.5-in paper tape; external splints are applied for osteotomies, and intranasal Doyle splints and intranasal packs are used sparingly. Patients are given prophylactic antibiotics to cover general skin flora and strict activity restrictions until the first postoperative appointment at 1 week. At that time, dressings and splints are removed (as are K-wires or screws for dorsal augmentation). Full activity is resumed at 2 to 4 weeks postoperatively.
POTENTIAL COMPLICATIONS AND MANAGEMENT
Fig. 18. Deviation and curvature of the dorsal septum causing a twisted nose and middle vault collapse.
Low dorsal height and saddle nose Cause: Overresection of dorsal hump Consequence: Cosmetic deformity, may lead to nasal obstruction and static/dynamic valve collapse Treatment: dorsal augmentation Pollybeak and supratip deformity Cause: Blood filling the potential space of the supratip after dorsal hump overresection, which incites an inflammatory reaction and fibrosis obscuring the supratip break.
93
Allak & Park
94
Also caused by cartilaginous underresection and residual anterior septal angle Consequence: Cosmetic deformity Treatment: Initially taping, deep steroid injections as early as 6 to 8 weeks, and revision surgery only after 6 to 12 months. Reresection if anterior septal angle remains Inverted V deformity Cause: Collapse of ULC at internal valve after inadequate resuspension or loss of suspensory support at K-area Consequence: Cosmetic deformity, nasal obstruction Treatment: Resuspension, possible spreader grafts Open roof deformity Cause: Inadequate reapproximation of nasal bones after bony dorsal hump reduction Consequence: Cosmetic deformity Treatment: Lateral osteotomies, possible small dorsal onlay if inadequate bone remains to cover the defect Graft infection Cause: Bacterial colonization and infection of implanted materials Consequence: Delayed healing, graft loss, or need for explant Treatment: Initially antibiotics and local wound care; operative explant for persistent infections and future revision Graft migration (dorsal augmentation) Cause: Inadequate securing of graft to underlying dorsum Consequence: Cosmetic deformity Treatment: Repeat suspension with taping, wires, or screws. May require revision if graft fixes in improper location Nasal valve collapse Cause: Improper ULC suspension, underestimation of graft size, persistent septal deviation Consequence: Nasal obstruction Treatment: May eventually require surgical revision
SUMMARY Understanding the middle nasal vault is important for rhinoplasty surgeons. Given its complex 3dimensional anatomy and vulnerability to esthetic deformity and internal valve collapse, consideration should always be given to the effect that common rhinoplasty maneuvers will have on the middle third of the nose. Identifying and addressing potential pitfalls of the middle vault during
primary rhinoplasty will lead to better outcomes and more satisfied patients.
REFERENCES 1. Yu K, Kim A, Pearlman SJ. Functional and aesthetic concerns of patients seeking revision rhinoplasty. Arch Facial Plast Surg 2010;12:291–7. 2. Saban Y, Amodeo CA, Hammou JC, et al. An anatomical study of the nasal superficial musculoaponeurotic system. Arch Facial Plast Surg 2008; 10(2):109–15. 3. Toriumi DM. Management of the middle nasal vault in rhinoplasty. Op Tech Plast Reconstr Surg 1995; 2(1):16–20. 4. Kasperbauer JL, Kern EB. Nasal valve physiology: implications in nasal surgery. Otolaryngol Clin North Am 1987;20:699–719. 5. Constantian MB. Differing characteristics in 100 consecutive secondary rhinoplasty patients following closed versus open surgical approaches. Plast Reconstr Surg 2002;109(6):2097–111. 6. Grymer LF. Reduction rhinoplasty and nasal patency: change in the cross-sectional area of the nose evaluated by acoustic rhinometry. Laryngoscope 1995;105(4 Pt 1):429–31. 7. Taub PJ, Baker SB. Operative atlas of rhinoplasty. New York: McGraw-Hill, Inc; 2011. 8. Mowlavi A, Meldrum DG, Wilhelmi BJ. Implications for nasal recontouring: nasion position preferences as determined by a survey of white North Americans. Aesthetic Plast Surg 2003;27(6):438–45. 9. Toriumi DM, Johnson CMJ. Open structure rhinoplasty: featured technical points and long-term follow-up. Facial Plast Surg Clin North Am 1993;1: 1–22. 10. Byrd HS, Meade RA, Gonyon DL Jr. Using the autospreader flap in primary rhinoplasty. Plast Reconstr Surg 2007;119(6):1897–902. 11. Clark JM, Cook TA. The ’butterfly’ graft in functional secondary rhinoplasty. Laryngoscope 2002;112: 1917–25. 12. Guyuron B, Michelow BJ, Englebardt C. Upper lateral splay graft. Plast Reconstr Surg 1998; 102(6):2169–77. 13. Park SS. The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg 1998;101:1120–2. 14. Prendiville S, Zimbler MS, Kokoska MS, et al. Middle-vault narrowing in the wide nasal dorsum: the “Reverse Spreader” technique. Arch Facial Plast Surg 2002;4(1):52–5. 15. Murakami C. Nasal valve collapse. Ear Nose Throat J 2004;83:163–4.