In the November 2021 issue of the Plastic and Reconstructive Surgery journal an article was published on ‘Why Primary Rhinoplasty Fails’. A previous discussion of their preoperative factors that contribute to undesired rhinoplasty outcomes has been done. Now onward to discuss the intraoperative techniques to help prevent common postoperative rhinoplasty problems.
Creating A Functional Problem
The concern about a postoperative nasal shape issue is magnified when functional airway issues have resulted as well. Airway compromise can occur from a variety of intraoperative issues. Lack of sufficient structural support and collapse/scarring of the internal nasal valves are primary culprits in creating airway compromise…much of which can happen from the dorsal reduction part of the rhinoplasty. These are often seen externally as disruption of the dorsal aesthetic lines. To help prevent this problem, the authors uses a graduated technique for reduction of the nasal dorsum. (upper cartilage release, septal height reduction, nasal bone rasping and dorsal line reconstruction. (which could be done by autospreader grafts if sufficient upper lateral cartilage remains or septal spreader grafts if not) What I have always liked best about this dorsal reduction approach is that it prevents an initial over reduction and you keep working gradually towards the reductive goal.
How the nose heals around its reshaped osteocartilaginous support is a major determinant of a rhinoplasty outcome. The thickness of the nasal skin, the creation of dead spaces, immediate postoperative blood oozing and the degree of overall nasal reduction are all well known factors that can lead to scar tissue formation and resultant unpredictable soft tissue contraction. Surgical technique definitely influences the amount of dead space as well as postoperative blood formation. The least amount of structural reduction as possible to achieve the and limiting the amount of dissection (tissues released) helps limit how much soft tissue contraction can occur. For control of blood into the released tissues the authors recommend the intraoperative use of TXA (tranexamic acid) by both IV and topical application which improves hemostasis during surgery and bruising afterwards through clot stabilization. Since its side effects are very few and its cost is very low there is no reason not to consider its use.
Lack Of Structural Support
An inability to resist wound contracture around the nasal tip is a common reason for postoperative loss of tip projection. While columellar strut grafts have historically been believed to provide the best method of maintaining tip support, this is not as effective as once thought. (it does effectively unify the nasal tip however) The authors recommend a septal extension graft to control both tip projection and rotation which extends from the anterior septal angle into the interdomal space. With the base platform of the septum it is easy to see why this supports the tip better than the more flexible tip cartilages alone.
Alar rim deformities, such as nostril asymmetry, alar rim retraction and notching, are not uncommon postoperative patient complaints. The use of an extended alar contour graft alone or combined with a retrograde alar contour graft placed through the lower inner rim of the nostril during primary rhinoplasty reduces these risks considerably. These are small grafts that often can be obtained from the discards from upper and lateral cartilage resections.
Dead Space Closure
Elimination of dead space is an often overlooked concept in rhinoplasty but its importance can not be overstated. Most of the maneuvers to do so are done during closure. Back and forth suturing over the membranous septum and supra tip spanning sutures are two examples. The authors describe an infratip lobule butterfly graft to counteract the void left behind by the cephalic trim of the lower alar cartilage to prevent alar rim retraction.
What is never closed during the internal mucosal closure is the soft tissue triangle area. It is left open and packed with antibiotic impregnated surgicel.
Immediate taping and splinting to compress the skin down over the modified osteocartilage framework is a well known method to reduce dead space. This may be combined with either internal septal quilting sutures or plastic septal splints sutured into place.
Dr. Barry Eppley