Inservice Exam - 2005
Cosmetic Rhinoplasty / Chin

Two months after cosmetic rhinoplasty, a patient has numbness of the nasal tip. The most likely explanation is injury to which of the following nerves?

(A) Descending branch of the infraorbital
(B) Descending branch of the lesser palatine
(C) External branch of the anterior ethmoidal
(D) Medial branch of the infratrochlear
(E) Medial branch of the nasopalatine

The correct response is Option C.

Knowledge of the innervation of the nose is necessary for local anesthesia in rhinoplasty and nasal reconstruction.

The anterior ethmoidal nerve enters the nose near the crista galli and has two branches. The external branch emerges between the nasal bone and the lateral nasal cartilage and supplies the skin of the nasal tip and alae. It is vulnerable during tip cartilage dissection. The internal branch of the anterior ethmoidal supplies sensation to the septum and the internal nasal walls.

The infraorbital nerve supplies sensation to the cheek, lip, lower eyelid, and the upper gingiva. The nasopalatine runs anteroinferiorly on the nasal septum in a groove in the vomer. It supplies sensation to the septum and the hard palate.

The lesser palatine innervates the uvula, tonsil, and soft palate. The infratrochlear nerve supplies the skin of the radix. All of these nerves are branches of the fifth cranial nerve.


References:
1. Bannister LH, Berry MM, Collins P, et al, eds. Gray=s Anatomy. 38th ed. New York: Churchill Livingstone, 1995:1233-1234.
2. Oneal R, Izenberg P, Schlesinger J. Surgical anatomy of the nose. In: Daniel RK, Ed. Rhinoplasty. Boston, MA: Little Brown; 1993:10-11.



A 19-year-old man has numbness of the left lower lip four weeks after undergoing transoral placement of a Silastic chin implant. Physical examination shows superior displacement of the left wing of the implant. Which of the following is the most appropriate management?

(A) Injection of a corticosteroid
(B) Massage
(C) Observation
(D) Reoperation
(E) Taping

The correct response is Option D.

Reoperation should be done as soon as possible. The implant should be surgically revised to remove pressure on the mental nerve caused by superior displacement of the implant. In a patient with numbness, leaving an implant in place for eight weeks or more may lead to permanent loss of sensation due to fascicular pressure and may require nerve repair.

Observation without intervention could lead to permanent injury. Taping of the chin is unlikely to be effective and may put additional pressure on the mental nerve. Massage and corticosteroid injection are not appropriate because they would not correct the underlying problem and would delay surgery, which could lead to permanent injury.

References:
1. Zide BM, Pfeifer TM, Longaker MT. Chin surgery: I. AugmentationCthe allures and the alerts. Plast Reconstr Surg. 1999;104(6):1843-1853.
2. Yaremchuk MJ. Improving aesthetic outcomes after alloplastic chin augmentation. Plast Reconstr Surg. 2003;112(5):1422-1434.




A 25-year-old woman comes to the office for postoperative follow-up 10 days after undergoing aesthetic rhinoplasty with rasping of a dorsal hump without the performance of cartilage grafts or osteotomy. Physical examination shows dorsal prominence with erythema but no fluctuance. Which of the following interventions is the most appropriate initial management?

(A) Needle aspiration and irrigation
(B) Observation
(C) Open excision
(D) Oral administration of an antibiotic
(E) Topical administration of an antibiotic


The correct response is Option D.

Because this patient has periostitis of the nasal dorsum, the most appropriate initial management is oral administration of an antibiotic to treat the infection. After the erythema resolves, the dorsal prominence can be surgically excised in 8 to 12 months. Studies show that shavings retained after dorsal rasping or saw osteotomy provide a nidus for periostitis. To reduce the risk of periostitis, all debris should be evacuated from the dorsum at the conclusion of dorsal rasping or saw osteotomy.

The other interventions are not appropriate for this patient. Observation delays treatment, which could lead to worsening infection. Topical administration of an antibiotic is ineffective in treating periostitis. Needle aspiration and irrigation and open excision are appropriate interventions to allow drainage and obtain cultures in the presence of fluctuance, which this patient does not have.


References:
1. Sheen J, Peebles Sheen A. Aesthetic Rhinoplasty. 2nd ed. St. Louis, MO: Mosby-Year Book; 1987:568-577.
2. Rees TD. Postoperative considerations and complications. In: Rees TD, ed. Aesthetic Plastic Surgery. Philadelphia: WB Saunders; 1980:708-727.





Resection of the cephalic borders of the alar cartilages and caudal septum during rhinoplasty is most likely to have which of the following effects?

(A) Decrease the alar flare
(B) Lengthen the nose
(C) Lower the columella
(D) Move the tip cephalad
(E) Shorten the nasal bones

The correct response is Option D.

Resection of the cephalic borders of the alar cartilages and caudal septum is frequently done by directly accessing anatomic structures during open rhinoplasty or by intracartilaginous, infracartilaginous, marginal, or transfixion incisions when an intranasal approach is used. Cephalad resection of the lateral alar crus moves the tip of the nose cephalad, decreases its fullness, and increases the definition of the projecting points of the dome. During this surgery, care should be taken to avoid weakening the support of the nostril arch by overresecting.
The other effects listed do not occur with resection of the cephalic borders of the alar cartilages and caudal septum during rhinoplasty. Alar wedge (Weir) resection is commonly used to decrease alar flare. Resection of the caudal septum usually shortens the nose by allowing the tip of the nose to move cephalad with minimal change in the nasolabial angle. This maneuver also raises the columella relative to the alar margin and makes the upper lip appear longer. The nasal bones are not affected by manipulation of the soft-tissue tip-lobule complex.

References:
1. Rohrich RJ, Muzaffar AR. Primary rhinoplasty. In: Achauer BM, Eriksson E, Vander Kolk C, et al, eds. Plastic Surgery: Indications, Operations, and Outcomes. Vol 5. St. Louis, MO: Mosby; 2000:2631-2672.
2. Guyuron B. Dynamic interplays during rhinoplasty. Clin Plast Surg. 1996;23:223-231.
3. Tebbets JB. Shaping and positioning of the nasal tip without surgical disruption: a new, systematic approach. Plast Reconstr Surg. 1994;94(1):61-77.




A 21-year-old man comes to the office for consultation regarding rhinoplasty because of a large dorsal hump. Effective surgical interventions to eliminate this patient’s deformity include each of the following EXCEPT

(A) augmentation of a saddle-nose deformity
(B) augmentation of the radix with a dorsal implant
(C) rasping of the hump
(D) resection of the hump, followed by osteotomy and infracturing of the nasal bones
(E) separation of the upper lateral cartilages from the nasal septum using a transmucosal incision

The correct response is Option E.
The nasal dorsal hump is predominently cartilaginous (57%) rather than bony (43%). Humps are classically resected by osteotomy. If an open-roof deformity is created, infracture should be additionally performed. Some surgeons prefer rasping the hump for fine control and shaping.

The cartilaginous portion of the hump consists of the nasal septum and the upper lateral cartilages. These structures can be resected as a unit sharply. Separating the upper lateral cartilages from the septum is not necessary and can compromise the support of the nose.

Some humps are prominent due to lack of height at the radix or the supratip area. For patients with a low caudal nasofrontal junction, a dorsal implant can give the illusion of a reduced hump. Similarly, if a patient has a saddle nose, correction of this defect will make a hump less conspicuous.


References:
1. Daniel RK, Lessard ML. Rhinoplasty: a graded aesthetic-anatomical approach. Ann Plast Surg. 1984;13:436
2. Constantian MD. An alternate strategy for reducing the large nasal base. Plast Reconstr Surg. 1989;83:41.
3. Peck GC. Basic primary rhinoplasty. Clin Plast Surg. 1988;15(1):15-27.




Each of the following is a general characteristic of the Asian nose EXCEPT

(A) alar flare
(B) bulbous nasal tip
(C) columellar show
(D) thick subcutaneous tissue
(E) wide flat dorsum

The correct response is Option C.

Columellar show is not a usual characteristic of the Asian nose. Although no two noses are alike, common anatomic characteristics among Asian patients include alar flare, a bulbous nasal tip, a short retracted columella, thick subcutaneous tissue, and wide flat nasal dorsum. The base view of the nose commonly shows a flat columella-alar triangle with hanging ala and a poorly projecting nasal tip. All of these characteristics should be considered when evaluating an Asian patient for rhinoplasty.

Asian rhinoplasty is one of the most commonly performed cosmetic procedures in the world. Such surgeries usually focus on augmentation of the nasal dorsum with an alloplastic implant. Different alloplastic materials, sizes, and shapes of implants have been used with varying degrees of success. Although silicone implants for nasal augmentation have been popular throughout Asia, such implants are not as popular in the United States. An important consideration in implant surgery is the thickness of the overlying nasal soft tissues to minimize implant extrusion.


References:
1. Matsunaga R. Augmentation rhinoplasty of Asian noses. Facial Plast Surg Clin North Am. 1996;4:75-85.
2. Fernandez MO. Silicone implants for augmentation rhinoplasty. Facial Plast Surg Clin North Am. 1996;4:55-62.
3. McCurdy JA. Augmentation rhinoplasty: implant selection and design. Facial Plast Surg Clin North Am. 1996;4:87-92.