SM14: Otolaryngologists Share Surgical Tips on Functional Rhinoplasty

Experts offered tips for navigating challenges in rhinoplaty.

During the session “Technical Pearls for Functional Rhinoplasty,” panelists offered wisdom gathered from years of experience performing the procedure. Here are a few highlights.

Managing the Inferior Turbinate

Alex Chiu, MD, interim chair of surgery and chief of otolaryngology-head and neck surgery at the University of Arizona in Tucson, offered tips for surgery on the inferior turbinate.

A recent study concluded that submucous resection with outfracture, with microdebrider assistance, is the most effective technique for inferior turbinate reduction, said Dr. Chiu (Laryngoscope. Published online ahead of print on September 19, 2013; doi: 10.1002/lary.24182). He advised that everything in the procedure should be done using the endoscope. “Everything in surgery should be with a focus, even putting in cotton pledgets,” he said. “So use an endoscope, [and] de-congest the area you need to work on as opposed to just kind of shoving those pledgets into the nose.”

For the submucous resection, he prefers a linear incision along the inferior turbinate, which helps with exposure, minimizing the chance of getting into trouble with arterial bleeding from the artery located posteriorly along the inferior turbinate.

He also likes epinephrine-soaked pledgets for hemostasis and as a technique for retracting tissue to free mucosa from the bone.

Septoplasty

The trick in septoplasty is creating enough room by modifying the surrounding structures, while preserving enough of the septum itself, said Scott Stephan, MD, assistant professor of otolaryngology at Vanderbilt University in Nashville. “In the modern era there’s more modification of the cartilage in the septum versus in earlier years, [when there was] more of an approach to resect the cartilage,” he said. It’s important to recognize the role of the septum in supporting the middle vault and the tip and to preserve those structural parts of the septum, “much like weight-bearing walls in a house.”

“If you want to modify the septum, you have to know what factors influence it,” he added. Those factors include bone, upper lateral cartilage, and soft tissue. “All of this contributes to a boundary that the septum has to live within, and if you, over time, have too small of a box, then you’re a six-foot man in a five-foot box,” Dr. Stephan said.

Modifying intrinsic features includes resecting bony deviations; modifying the cartilage by scoring the concave side, cross-hatching, and morselizing non-critical areas; and using vertical slats in the dorsum.

For severe dorsal deviation, Dr. Stephan advised that an extra-corporeal septoplasty might be best. A small portion of the dorsal septum is kept intact so that it can be used as an anchor point for the L-strut carved from the resected portion of the cartilage.

He also touched on the use of polydioxanone plates when fragments of cartilage can’t be manipulated into the desired outcome: The fragments are placed on the plate, which induces cartilage growth, starts to resorb after 10 days, and is gone after 25 days. “It does align the cartilage that does fuse together better than if you had just sewn those cartilage pieces together alone,” Dr. Stephan said.

The Twisted Nose

Jared Christophel, MD, assistant professor of otolaryngology-head and neck surgery at the University of Virginia in Charlottesville, offered advice on straightening the upper third of the nose. “If the perpendicular plate of the ethmoid in the keystone area is not able to be set straight, it will … set the rest of the nasal dorsum off in that direction,” he said, adding that this can be a particularly tough job using only standard techniques.

Using a fulcrum can help, he advised. He starts with a fading medial osteotomy on the contralateral side and a lateral osteotomy on the contralateral side, then puts the osteotome up into the frontal bone to fulcrum the contralateral side away from the side of the deviation. “This allows that central portion of the perpendicular plate of the ethmoid to be broken over and moved with it.”

Correction of the Collapsed Nasal Dorsum

Edward Farrior, MD, president of the American Academy of Facial Plastic and Reconstructive Surgery and founder of Tampa-based Farrior Facial Plastic Reconstructive and Cosmetic Surgery Center, outlined his approach to the collapsed dorsum:

• He prefers a complete release of the cartilage: “I think it’s important to mobilize the mucoperichondrial flaps so that you can move things and have free movement of the upper lateral cartilages and medial crus.”
• He is not inclined to use unilateral spreader grafts: “My philosophy is I do things pretty much symmetric in the nose … I believe more in freeing things up and putting spread grafts on both sides rather than trying to open the nasal valve by putting a spreader graft on one side.”
• The spreader grafts can be extended above the nasal dorsum for supratip augmentation.
• He cuts a wedge in the top of the spreader grafts, “so that as the spreader graft is sutured beneath the upper lateral cartilage it can extend beneath the bony cartilaginous juncture. And having that wedge on the superior part helps to hold it in place when you do your osteotomies” and perform other tasks.
• Retro-displacing: He preserves all the length in the lateral crus. “When you set it back and suture it to the septum, it will create a little bit of a flare so that you haven’t shortened the distal portion of the lateral crus,” increasing the internal nasal valve. “You do only what is necessary, but be sure to do everything that is necessary.”

Lateral Wall Support

Stephen Park, MD, director of facial plastic and reconstructive surgery at the University of Virginia in Charlottesville, emphasized the importance of precise placement of batten grafts when correcting a dynamic collapse.

The “biggest bang for your buck” will come from supporting the area between the external and internal nasal valves, the inter-valve area. This spot corresponds to the supra-alar crease externally and the lateral aspect of the lateral crus structurally. A deep supra-alar crease is often a sign that the inter-valve area is a contributor to the obstruction. “You just lift that spot just a touch, a couple millimeters, and the patient will say, ‘That’s it, whatever you did, Doc, that’s exactly what I need you to do,’” Dr. Park said.

When he does a revision functional rhinoplasty, the initial operative note usually sounds perfect, but when he goes in, the most common mistake is usually that the batten graft has been placed in the wrong spot; frequently it is incorrectly sitting on top of the lateral crus and occasionally on the nasal bone. “Precise placement of this batten graft, I believe, is key,” he said. “It’s non-anatomic, it’s not on top of cartilage, but within the soft tissue area of the lateral nasal wall. It is then suture secured.”