Husain Ali Khan, DMD, MD,† Alireza Jahangirnia, DMD, MD,‡
Samiei Sahand Rad, DMD,§ and
Hossein Mortazavi, DMD, MD, FICS�
Purpose: Primary cosmetic rhinoplasty is one of the most complex of cosmetic surgical procedures in themaxillofacial area that requires precise consideration to both form and function. The complex and variableanatomy, highly visible position of the nose, and distinct patient desires contribute to the complexity of thisprocedure. This study reports the combined results of 101 consecutive primary cosmetic rhinoplasties at 2 centers.
Patients and Methods: A retrospective chart review was completed on all patients who had primarycosmetic rhinoplasty with or without septoplasty and who were operated on by the senior authors (S.C.B. andH.M.) from June 2006 through December 2008. A standard physical examination, including photo documen-tation, was completed on each patient preoperatively. All patients were followed periodically after surgery forat least 12 months. Outcome was measured by both subjective and objective measures of cosmetic andfunctional (breathing) outcome. The following data were collected and analyzed: age of patient, gender, chiefcosmetic and functional complaint, details of surgical procedure (including septoplasty, grafts, and donorsites), complications, and report of subjective outcome at final evaluation.
Results: One hundred one patients (n � 101, average age 24.4 � 6.8 years old) were enrolled in thestudy. Most patients presented for consultation regarding cosmetic rhinoplasty (80%) versus septorhi-noplasty (20%). Although most of the patients (63%) were treated with septorhinoplasty, the openrhinoplasty (transcollumellar) incision was used in 61% of patients versus the closed rhinoplasty (39%)technique. The most commonly performed combination of techniques used was the combination ofnasal tip modification, with dorsal reduction and nasal osetotomies (54%), followed by tip modificationwith dorsal reduction (19%), and dorsal reduction with osteotomies (18%) and no tip modification. In the50 patients who required a graft, in 80% the donor site was the nasal septum. Spreader grafts were usedin 14% of patients, and a combination of shield/tip graft was used in 52%. The following complicationswere observed: unhappy patient 16%, dehiscence at incision 5%, asymmetry requiring revision 6%, andinfection 1%. In the 63 patients that had septoplasty, 6 (9.5%) reported that their breathing was notimproved. In this series 11 patients (11%) received a revision rhinoplasty.
Rhinoplasty has evolved based on advancements insurgical technique that survive the test of time andincreasing patient expectations. Cosmetic surgery isunique among other surgical specialities due tochanging trends and racial and regional ethnic pref-erences that drive the patient desires to what is con-sidered an esthetic result. In no other procedure aresuch differences so evident as in rhinoplasty. Theoperation is individually customized to account forcurrent ethnic and cultural norms.1,2 In modern rhi-
oplasty surgery, no single procedure or approachan provide such a vast array of patient desires foreauty and functionality. Surgeons have to be armedith multiple techniques based on patient demandssed in concert to give predictable results. Cosmetichinoplasty remains one of the most challenging facialosmetic procedures. This is unlikely to change de-pite many advances and changes in this field.
The desire to perform rhinoplasty is dictated byeveral factors. Congenitally or acquired (via trauma)asal deformities such as crooked, deviated, or col-
apsed nasal structures are common etiologies forosmetic rhinoplasty. Such deformities are frequentlyombined with functional disturbances (most com-only deviated septum causing impaired airflow) thatarrant combined cosmetic and functional septorhi-oplasty. The patient’s desire for a more attractive orfashionable” nose is also an important factor. Thistandard is constantly changing and is largely dictatedy media, crossing all regional and ethnic barriers.herefore, the need for nasal cosmetic surgery isriven by the combination of pre-existing deformitiesnd/or the patient’s request for a more esthetic nose.
The purpose of this article is to present the demo-raphics, results, and complications of 101 consecu-ive primary cosmetic rhinoplasties at 2 oral and max-llofacial surgery centers.
Patients and Methods
A retrospective chart review was completed on allpatients who had primary cosmetic rhinoplasty withor without septoplasty and which were operated onby the senior authors (S.C.B. and H.M.) from June 30,2006 through December 31, 2008. A standard physi-cal examination, including photo documentation, wascompleted on each patient preoperatively. All pa-tients were followed periodically after surgery for atleast 12 months. Outcome was measured by bothsubjective and objective measures of cosmetic andfunctional (breathing) outcome. The following datawere collected and analyzed: age of patient, gender,chief cosmetic and functional complaint, details ofsurgical procedure (including septoplasty, grafts, anddonor sites), complications, and report of subjective
outcome at final evaluation. All patients with a prior m
history of rhinoplasty or facial trauma that involvedthe nasal complex were excluded from the study.Given the retrospective nature of this study, the re-search was exempt from our institutional reviewboard ethics committee.
Results
One hundred one patients (n � 101, average age24.4 � 6.8 years old, female � 62, males � 39) werenrolled in the study. Most patients presented foronsultation regarding cosmetic rhinoplasty (80%)ersus septorhinoplasty (20%). Although most of theatients (63%) were treated with septorhinoplasty,he open rhinoplasty (transcollumellar) incision wassed in most cases (61%) versus the closed rhino-lasty (39%) technique. The most commonly per-
ormed operative technique used was the combina-ion of nasal tip modification, with dorsal reductionnd lateral nasal osetotomies (54%), followed by tipodification with dorsal reduction (19%), and dorsal
eduction with osteotomies (18%) with no tip modi-cation. In the 50 patients who required a graft, theasal septum was used as the donor site in 80% ofatients. Spreader grafts were used in 14% of patients,nd a combination of shield/tip graft was used in 52%.or the purpose of this article, complications wereivided into acute (within first 6 months) and chronicbeyond 6 months). The most common complicationas the patient expressing some degree of dissatisfac-
ion (unhappy patient) with the final cosmetic orunctional result at 1 year (16%). Minor dehiscence athe incision was seen in 5% of patients acutely, de-ned as a prolonged erythema at the incision sitesith visible wound margins. All cases of minor dehis-
ence resolved with no significant scar formation at-year follow-up, including the 1 patient who devel-ped an infection at the site of the transcollumellar
ncision. No cases of major wound dehiscence wereeen at follow-up. No patients complained about vis-ble scars at 1-year follow-up. The main complicationontributing to patient dissatisfaction was asymmetryequiring revision (6%). Another cause of dissatisfac-ion included the postoperative shape of the tip ororsum. Infection was seen in 1 patient (1%) (Fig 1).n the 63 patients that had concomitant septoplasty, 69.5%) reported that their breathing was not im-roved. This was the main functional outcome thatontributed to the 16 patients who reported dissatis-action with their surgeries. In this series, 11 patients11%) received a revision rhinoplasty or a secondurgery to address cosmetic or functional improve-ent.All surgical treatments were individually designed
o satisfy the patients’ expectations without compro-
ise of function. Figures 2-4 show pre- and postop-
dnti
904 ANALYSIS OF PRIMARY COSMETIC RHINOPLASTIES
erative view of 3 representative patients after openseptorhinoplasty.
Discussion
Rhinoplasty was traditionally developed as a cos-metic procedure to alter the shape of the nose via aclosed (endonasal) surgical access. This technique hassurvived the test of time and continues to be a prin-cipal approach for many surgeons.3 In the past 3
ecades many surgeons have embraced the open rhi-oplasty approach via a transcollumellar incision. Al-hough the literature may appear conflicting regard-ng the use of an open versus closed technique,4-6
both techniques can provide excellent results. Majordifferences in surgical technique, training, and visibil-ity are observed between the 2 methods.
Although the surgical treatment plans are depen-dent on the patient desires and are individualized foroptimal outcome, a series of surgical maneuvers fornasal modification have become recognized and areappropriately adapted to each patient. We review thebasic strategies used by the authors for modificationof the 4 anatomic regions of the nose (radix, dorsum,tip, nasal base).
RADIX MODIFICATION
Most radix modifications involve reduction or aug-mentation. Reduction is performed in harmony withdorsal and tip modifications. This was generallyachieved using a rasp or osteotome via a closed oropen access. The radix has to be “balanced” to matchthe dorsum. Reduction of the radix alone will furtherenhance the projection of the nasal dorsum. Radix
FIGURE 1. A patient presenting with infection at the site of thetranscollumellar incision several months after open rhinoplasty withan alloplastic graft (MEDPOR) for tip modification.
Bagheri et al. Analysis of Primary Cosmetic Rhinoplasties. J OralMaxillofac Surg 2012.
augmentation procedures have been performed since
the 1930s. Many materials have been used for thispurpose, including septal or conchal cartilage, der-mis, fascia, and bone. We prefer the use of eithertemporalis fascia or acellular donated human dermis(Alloderm). The temporalis fascia can be easily har-vested via a temporal incision within the hairline. Thegraft is subsequently inserted at the radix upon com-pletion of the rhinoplasty, using an attached needlethat is pulled through at the nasion point. We recom-mend overgrafting by 25% to 30% to account forsubsequent graft resorption and atrophy. It is com-mon for patients to become discouraged due to theamount of initial postoperative swelling with radixaugmentation that may persist for several weeks. Thepatient should be carefully counseled on this beforesurgery.
DORSUM MODIFICATION
Traditionally, the dorsum is altered to match theesthetics of the nasal tip. We emphasize the conceptof a “balanced” nose, where reduction and augmen-tation strategies are used to achieve harmony be-tween all components, therefore achieving the idealheight of the dorsum. Alterations of the nasal dorsumor the osseocartilagenous vault are complex and in-volve both cosmetic and functional factors. Reductionof the dorsum was usually performed by rasp. Thecartilagenous (upper lateral and septal cartilages) canbe excised with a scalpel or scissors. Depending onthe extent of reduction, an open book deformity mayresult that can be addressed using lateral nasal osteot-omies. Narrowing of the nasal vault will affect theinternal nasal valve angle. Spreader grafts can be usedto prevent this complication. The combination ofsimultaneous medial and lateral osteotomies are lessfrequently used because of the difficulty in control-ling the mediolateral position of the nasal bone. Lat-eral nasal osteotomies are also used to decrease thewidth of the dorsum. These osteotomies are bestconducted through a small endonasal incision at theinferior and lateral aspect of the piriform rim. How-ever, some surgeons prefer to do this via a smalltranscutaneous stab incision. A thermoplastic nasalsplint was used after nasal osteotomies to stabilize thesegments and was kept in place for 1 to 2 weeks.
Dorsal augmentation can be achieved using allo-genic or alloplastic material. Septal and ear cartilagecan be used for minor augmentation in conjunctionwith fascia or acellular dermal grafts. Major dorsalreconstruction is best achieved with of rib (carti-lage and bone) or iliac crest; however, no cases ofdorsal reconstruction are reported in our series. Inour experience most dorsal reconstructions usingcostochondral grafts have been performed in revi-sion rhinoplasty. Alloplastic materials such as sili-
cone or porous polyethylene (Medpore; Stryker
l Maxil
BAGHERI ET AL 905
CMF, Newnan, GA) are less frequently used be-cause of frequent postoperative complications(graft movement, infection, dehiscence).
TIP MODIFICATION
We find the nasal tip surgery to be the most difficultand challenging part of cosmetic rhinoplasty, andtherefore, the cause of patient dissatisfaction despitean apparent good result from the surgeon’s perspec-tive. This can be due to several factors: 1) descriptionof the desired postsurgical nasal tip form can bedifficult for the patient and surgeon; 2) the nasal tip
FIGURE 2. Pre- (2A1) and post- (2A2) operative frontal views aftea 25-year-old male. Pre- (2B1) and post- (2B2) operative lateral vi
Bagheri et al. Analysis of Primary Cosmetic Rhinoplasties. J Ora
surgery has many variations; 3) nasal tip anatomy is
more complex and cosmetically apparent; 4) strictlimitations in size reduction and alteration of form.Adherence to sound surgical techniques and empha-sis on minor tip changes allow a more controlledoutcome. The nasal tip can be analyzed by 6 charac-teristics: volume (based on size of lateral crura), width(interdomal distance), shape (broad, bulbous, boxy),projection, rotation, and definition. These character-istics are interrelated and are not strictly indepen-dently modified (eg, cephalic lateral crura resection isprimarily performed to reduce the tip volume, but italso increases projection and alters the definition).
tive rhinoplasty for dorsal reduction with minor tip modification inmonstrating reduction of the bony and cartilagenous dorsum.
lofac Surg 2012.
r reducews de
Understanding of this allows the surgeon to better
l Maxil
906 ANALYSIS OF PRIMARY COSMETIC RHINOPLASTIES
visualize the final outcome. Surgical treatment plansthat alter the tip are designed to modify these char-acteristics.
NASAL BASE MODIFICATION
When indicated, nasal base modifications are per-formed as an integral part of primary cosmeticrhinoplasty. This area is complex and integratesanatomically with the alar base, nostril openings,external nasal valve, columella, and tip. The vastmajority of alar base modifications include an alar
FIGURE 3. Pre- (3A1) and post- (3A2) operative frontal of a 22-yelateral views demonstrating dorsal reduction and tip modification.the dorsum and tip.
Bagheri et al. Analysis of Primary Cosmetic Rhinoplasties. J Ora
base wedge excision, a nostril sill/floor excision, or
both. The resulting scar is well concealed and in-frequently causes any complications. The nostril sillexcision is extended into the floor of the nose andcan be used to reduce the size and visibility of thenostril floor on frontal view. The alar wedge exci-sion is made in a curvilinear fashion just superior tothe alar crease. This excision will reduce the alarflare and is commonly used in African Americanrhinoplasty. The 2 incisions can be combined toachieve reduction in alar flare and nostril size. Theintraoral alar cinch procedure can also be used to
atient after open rhinoplasty. Pre- (3B1) and post- (3B2) operativetient was very satisfied with the results and the “balance” between
lofac Surg 2012.
ar-old pThe pa
reduce the alar width.
l Maxil
BAGHERI ET AL 907
GRAFTS
Grafting is an important part of modern rhino-plasty. Multiple autogenous donor sites and severalalloplastic grafting materials are available. We usedautogenous cartilage grafts for the majority of primarycosmetic rhinoplasties.
Septal cartilage was the primary choice for mosttip, columella, alar, and dorsal cartilage grafting. Incases where the septal cartilage was not available(previous septoplasty or secondary rhinoplasty), theconcha was harvested. Temporalis fascia and decellu-larized human dermis (Alloderm) were used as graftsfor radix or other soft tissue grafting.
In our series of 101 cases, 61% were performedopen versus 39% closed. The decision to perform anopen versus closed approach was primarily based onthe complexity of the treatment plan and the surgicalpreference of the surgeon. All patients requiring com-plex tip modifications were conducted using theopen approach. However 64% (25 of 39) of the closedrhinoplasty cases did involve minor tip modifications.We do not routinely adhere to performing open rhi-noplasty on all patients requiring tip modification.Many surgeons strictly use the open or closed surgicalaccess for all cosmetic rhinoplasties. In our experi-ence we emphasize a combination of open and closedtechniques, although successful outcomes can be
FIGURE 4. (A-H) Pre- and postoperative photographs of a 53-yearThe surgical procedure included dorsal reduction and tip plasty (cpatient’s primary concern was the size of the dorsal hump. She dappearance” of her dorsum and tip.
Bagheri et al. Analysis of Primary Cosmetic Rhinoplasties. J Ora
achieved via exclusive adherence to either technique.
In the closed rhinoplasty, the access to the nasalstructures is usually via a combination of partial or com-plete transfixion incisions along with an intercartilag-enous (between the lower and upper lateral cartilages)or intracartilagenous (cartilage splitting) incision. Simul-taneous septoplasty or turbinate reduction can be per-formed via separate incisions. The Killian incision wasused in our series for access to the nasal septum whensimultaneously using a hemitransfixion incision. Wecharacteristically place the incision at least 5 to 8 mmposterior to the caudal edge of the septal cartilage toavoid compromising the hemitransfixion access. Thecartilage delivery technique was used to directly visual-ize and alter the lower lateral cartilage and tip. In ourexperience the most difficult challenge of the closedrhinoplasty approach is to achieve a predictable anddesired alteration of both bony and cartilage structuresvia minimal direct visualization of altered structures intheir anatomic passive relationships. Unlike bony alter-ations, cartilage has memory, and maintaining the carti-lage in the desired position is difficult, but can beachieved using a variety of cartilage modifications (scor-ing, transection, repositioning, trimming, sutures, andgrafting). Originally, the closed technique was predom-inantly a reductive technique involving dorsal reductionand nasal osteotomies. Nasal tip modifications were con-sidered difficult and only amenable to minor changes.
tient who underwent cosmetic rhinoplasty and caudal septoplasty.lateral crural resection, interdomal and tip defining sutures). This
an overall reduction in the size of her nose without the “ski-slope
lofac Surg 2012.
-old paephalicesired
Although this remains to be true, equally complex tip
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908 ANALYSIS OF PRIMARY COSMETIC RHINOPLASTIES
modifications can be performed via the closed tech-nique4; however, this requires greater training tochieve the surgical comfort and desired final estheticutcomes. Grafting of the nasal tip structures can behallenging via the closed approach and requires com-lex understanding of the tip. Graft movement andtability are among the few problems that the surgeonay encounter.We find that an advantage of the closed rhinoplasty
echnique is the speed, lesser dissection, and absencef a skin incision. It can be hypothesized that whenompared with the closed approach, the open tech-ique (especially without strut grafting) will result inome degree of long-term nasal tip collapse due to theoft tissue retraction, scarring, and weakening of theoot plates of the lower lateral cartilages. In this seriesf 61 open rhinoplasties with at least 1-year follow-upe did not encounter complications related to col-
apse of the nasal tip. It should be noted that the noseoes continue to age and ideally only accurate long-erm follow-up (over 10 years) may show long-termtructural complications.
An important addition to the functional rhinoplastyurgery was the placement of spreader grafts to pre-erve or increase the nasal valve angle that directlyorrelates with the respiratory function of the nosend a method for reconstruction of the roof of theiddle nasal vault.7,8 This can be particularly impor-
tant especially with reduction of the dorsum widthand in correction of the pinched nose deformity.9 Thegraft is usually obtained from the nasal septum (orfrom the ear cartilage) and is positioned between thenasal septum and the upper lateral cartilages on bothsides as needed. In our series all spreader grafts wereplaced under direct vision and sutured into placeusing the open technique. Placement of spreadergrafts using the closed approach is possible but ismore difficult and potentially less stable. In our seriesof 69 open rhinoplasties, spreader grafts were used in14 patients (23%). The decision to use spreader graftswas based on the extent of mid dorsal vault reduc-tion/modification and pre-existing nasal valve compe-tency.
In the 62 open rhinoplasties we used the transcollu-mellar incision with bilateral marginal extensions, alsodescribed as the open rhinoplasty technique.5 We findhat 1 important advantage of the open access is thatt dramatically facilitates the teaching of rhinoplastyo our resident surgeons and significantly contributeso predictable nasal structural modifications. The re-lization of the flap viability and ability to modify andraft cartilage that has been stripped from its support-ng pericondrium has contributed to the success ofhis approach. Before this approach, students of rhi-oplasty would learn the complex anatomy and sur-
ical modifications of the closed rhinoplasty without c
isualization of the modified structures. This makeshe mastery of the technique extremely challenging.
e believe that the open approach has allowed moreapid understanding of the anatomy by our observingtudents, which may translate into a greater numberf surgeons who acquire the skills and interest for thisurgery. This flap allows the placement of complexrafts (shield, columella tip, supra tip, ala, spreader)nder direct vision. Although many experienced sur-eons may be able to achieve exceptional results andrafting via the closed approach, characteristicallyhis requires a prolonged and sustained learningurve: years of trial and error that may only bechieved later in one’s surgical career. We believehat the accelerated learning of nasal modifications viahe open approach is a great advantage to learningurgeons and their patients.
Disadvantages of the open rhinoplasty techniquenclude the slight increased operative time for flaplevation, the presence of the transcollumellar scar,nd paresthesia of the nasal tip. The scar is usuallyell concealed under the nasal tip and is not visiblen the frontal view. Five patients had prolongedrythema at the incision site that delayed the heal-ng. Although with appropriate wound care, allncisions healed without an unusually apparentcar. One patient developed an infection thataused drainage at the incision site under the col-mella (Fig 1). This patient was successfully treatedith antibiotics and recontouring of the alloplast
raft (MEDPOR), and subsequent careful soft tissuelosure to minimize scar formation. We prefer thenverted V transcollumellar incision to assist inroper alignment of the flap at closure, which alsoelps camouflage the scar. Keloid formation wasot seen in our group of patients. Temporary par-sthesia (hypoesthesia or anesthesia) of the nasalip was seen in all patients undergoing the openhinoplasty, although no patients complained ofersistent paresthesia at 1 year. We hypothesizehat strict adherence to the subperichondrial plane,nd when possible decreased disruption of the flap,an minimize this postoperative sequela.Concomitant septoplasty is frequently performed
n the primary cosmetic rhinoplasty patient. In ourroup of patients 20% underwent a septorhino-lasty. The septal cartilage was approached for
unctional (deviated septum) or used as a donor siteor cartilage reconstruction for the tip, ala, columel-ar strut, or spreader grafts. Traditionally, the septalartilage is accessed using an endonasal incisioneg, Killian, transfixion). The septal cartilage canlso be approached via the open technique foreptoplasty or cartilage harvest. This access wassed in 8 patients. As with the endonasal approach,
are was taken to maintain a minimum of 1 cm
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BAGHERI ET AL 909
dorsal and caudal cartilage for preservation of dor-sal support. Collapse of this cartilage can result inthe saddle nose deformity. None of our patientssuffered from this complication.
In our series 16 patients (16%) reported being un-happy with their initial results, of which 11% (11patients) underwent a successful revision procedure.The most common cause of dissatisfaction was unim-proved nasal breathing (6 patients) from the septo-plasty. Most cosmetic revision procedures (6 patients)were related to asymmetry correction of the dorsumand tip. All patients who reported dissatisfaction withtheir primary rhinoplasty were acknowledged andfollowed periodically. Revision rhinoplasty was con-ducted at least 9 months after the initial procedure.
In the 63 patients that had concomitant septo-plasty, 6 (9.5%) reported that their breathing was notimproved. This is consistent with other reports in theliterature10 and is generally attributed to the complex-ty of nasal anatomy and multifactorial nasal etiologyf airway obstruction.Primary cosmetic rhinoplasty is one of the more com-
lex facial cosmetic procedures. The vast majority ofomplications can be avoided with careful and exten-ive treatment planning; however, a proportion of pa-ients are anticipated to require a revision procedure. Inhis series we found a complication and revision rate
imilar to what is reported in the literature.11-15
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6. Anderson JR, Ries WR: Rhinoplasty: Emphasizing the ExternalApproach. New York, Thieme, 1986
7. Rohrich RJ, Hollier LH: Use of spreader grafts in the externalapproach to rhinoplasty. Clin Plast Surg 23:255, 1996
8. Sheen JH: Spreader graft: A method of reconstructing the roofof the middle nasal vault following rhinoplasty. Plast ReconstrSurg 73:230, 1984
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