In-Service Exam
Cosmetic - Rhinoplasty - 2001

In addition to the septal cartilage, which of the following structures should be examined carefully in the evaluation of traumatic deviation of the nasal septum?

(A) Ethmoid and maxilla
(B) Ethmoid and vomer
(C) Nasal bones and sphenoid
(D) Sphenoid and vomer
(E) Vomer and nasal bones

The correct response is Option B.

In addition to the septal cartilage, the ethmoid and vomer should be examined carefully in a patient who is being evaluated for traumatic deviation of the nasal septum. The osseous component of the septum, which lies posterior to the cartilaginous component, is comprised primarily of the ethmoid bone in its superior portion and the vomer bone in its inferior portion. Because nasal septal deviation can be either developmental or traumatic (associated with fracture of the nasal bones and/or ethmoid complex), any person with obstruction of nasal airflow should be evaluated for deviation after other causes have been ruled out. This deviation can result from the mechanisms of buckling, fracture, or dislocation.

In patients with confirmed septal deviation, surgery should address both the cartilaginous and bony components. Treatment of the ethmoid and vomer should involve removal of bone and not refracture and repositioning. Excision of the septal cartilage will result in the formation of an L-shaped strut along the caudal and dorsal edges. Scoring of the concave cartilage will help re-establish contour.

Although the sphenoid, nasal, frontal, maxillary, and palatine bones can come into contact with the nasal septum, their contributions are peripheral and therefore do not need to be evaluated in a patient with suspected traumatic deviation.

References
1. Netter FH. Atlas of Human Anatomy. Summit, NJ: Ciba-Geigy Corp; 1989:34.
2. Pick TP, Howden R, eds. Gray's Anatomy. New York, NY: Bounty Books; 1977:77-80, 116-117.
3. Ridenour BD. The nasal septum. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology Head & Neck Surgery. 3rd ed. Saint Louis, Mo: Mosby Ð Year Book; 1998;2:921-948.

In a patient who has just undergone open rhinoplasty, perfusion of the nasal tip depends primarily on which of the following arteries?

(A) Angular
(B) Columellar branch of the superior labial
(C) Dorsal nasal
(D) External branch of the anterior ethmoidal
(E) Lateral nasal

The correct response is Option E.

The blood supply of the nasal tip and columella is derived from the contributions of five vessels; three of these vessels are derived from the external carotid artery, while two are derived from the internal carotid artery. The facial artery arises from the external carotid artery and then divides into the angular and labial arteries. The lateral nasal artery, which is located in the subdermal plexus at a point 2 mm to 3 mm superior to the alar groove, usually arises from the angular artery. One study showed this to occur uniformly in 97% of cadavers. In contrast, the columellar branch of the superior labial artery was present in only 77% of cadavers in the study. This branch is divided during open rhinoplasty. Therefore, following division of the columellar branch, the lateral nasal artery provides perfusion to the tip of the nose.

The other collateral vessels that arise from the internal carotid artery are the dorsal nasal artery and the external nasal branch of the anterior ethmoidal artery. The dorsal nasal artery perforates the orbital septum and runs downward on the side of the nose, where it anastomoses with the lateral nasal artery. The external nasal artery is the final branch of the anterior ethmoidal artery; it emerges between the nasal bone and upper lateral cartilage and then anastomoses with the nasal tip plexus. These arteries are believed to be very minor contributors to blood flow to the nasal tip.

One anatomic study of open rhinoplasty suggested that extensive defatting of the nasal tip or extended resection of the nasal alar base above the groove should not be performed during open rhinoplasty because it would result in division of the lateral nasal arteries. A subsequent study separated the alar base excisions into minimal, standard, and extended excisions. It was then shown that only the extended base excision would result in division of the lateral nasal artery. It was also found that both limited and standard excisions of the alar base resulted in preservation of the lateral nasal artery. The study again emphasized that the lateral nasal artery was the major contributor to the nasal tip plexus.

References
1. Bafaqeeh SA, Al-Qattan MM. Simultaneous open rhinoplasty and alar base excision: is there a problem with the blood supply of the nasal tip and columellar skin? Plast Reconstr Surg. 2000;105:344.
2. Rohrich RJ, Gunter JP, Friedman RM. Nasal tip blood supply: an anatomic study validating the safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg. 1995;95:795.

PHOTO

The above photographs are of a 34-year-old woman who is disappointed with the aesthetic result 18 months after undergoing primary rhinoplasty. She says that her lower nose looks pointy and that she has nasal obstruction with deep breathing. On examination, she has alar collapse with inspiration.

Which of the following is the most appropriate operative management?

(A) Cartilage grafting to increase tip support
(B) Cephalic trimming of the lower lateral cartilages to increase nasal projection
(C) Osteotomies to narrow the upper nose
(D) Weir resections to decrease alar flare
(E) Trimming of the dorsal septum to correct the polybeak deformity

The correct response is Option A.

This patient has a polybeak deformity caused by excessive reduction during the primary rhinoplasty procedure, combined with poor projection of the nasal tip. The obstruction with inspiration is suggestive of alar collapse; the nasal tip is pinched and lacks support. The most appropriate next step in management is cartilage grafting of the nasal tip and alae to increase support.

Although the alae appear flared because of the absence of tip support, the lower lateral cartilages have already been trimmed excessively, and their appearance would only worsen with further trimming. In the same way, the upper nose appears wide because of the tip deficiency, but is instead an appropriate width, as demonstrated by the smooth curve from the rim of the brow to the nose, and would not benefit from osteotomies. Weir resections would only accentuate the pinched nasal tip. Because this patient's problems have resulted from excessive reduction of the dorsal septum, any further reduction would only worsen the deformity.

References
1. Peck G. Nasal tip projection: goals and maintenance. In: Rees TD, ed. Rhinoplasty: Problems and Controversies. Saint Louis, Mo: CV Mosby Co; 1988:10.
2. Sheen JH, Sheen AP. Problems in secondary rhinoplasty. In: Aesthetic Rhinoplasty. 2nd ed. Saint Louis, Mo: CV Mosby Co; 1987;2:1135-1408.

A 26-year-old woman who desires cosmetic rhinoplasty is scheduled to undergo rasping of the nasal hump and reshaping and grafting of the nasal tip followed by Weir excisions. Which of the following factors, if present, will decrease the likelihood of an optimal result in this patient?

(A) Mediterranean heritage
(B) Presence of a bony rather than cartilaginous hump
(C) Smoking history of one-half pack of cigarettes daily
(D) Thickened skin with prominent sebaceous glands
(E) Use of an open technique

The correct response is Option D.

Careful preoperative planning is an essential part of cosmetic rhinoplasty and will vary from patient to patient, depending on each patient's anatomy and desired result following surgery. A patient who primarily desires a smaller or defined nasal tip but has thick skin and prominent sebaceous glands will not experience the postoperative shrinkage necessary to fit the altered nasal cartilage framework; consequently, the nasal tip may still be larger than is desired by the patient. Consequently, the skin thickness should be assessed during preoperative evaluation and discussed with this patient in order to ensure that her expectations are appropriate.

Although people of different heritages have different anatomic traits and possibly different desires for aesthetic outcomes, a successful rhinoplasty can generally be accomplished with adequate planning and input from the patient, whatever his or her ethnicity.

The congenital dorsal hump is often comprised of 50% bone and 50% cartilage. Although the variation from patient to patient can be significant, either type of hump may be successfully reduced; however, different methods of reduction may be required. A small bony hump may be rasped, while larger humps may require the use of a saw or chisel.

A mild-to-moderate smoking history has not been shown to affect rhinoplasty, most likely because of the excellent blood flow within the nasal plexus.

Both open and closed rhinoplasty techniques can be successfully used in cosmetic rhinoplasty. Open rhinoplasty offers better visualization of the tip cartilage but is associated with greater postoperative edema and the potential development of an external scar. However, the type of exposure should not affect the outcome of the rhinoplasty.

References
1. Daniel RK. Rhinoplasty planning. In: Aesthetic Plastic Surgery. Boston, Mass: Little, Brown & Co; 1993:79-123.
2. Sheen JH. Closed vs. open rhinoplasty. Plast Reconstr Surg. 1997;85:99.