Daniel Simmen

Residual Deformities of the Columella

Columellaplasty is an important procedure in rhinoplasty. I can alter the length, width, shape, and prominence of the columella, and also the angle between the nose and the upperlip. There are many structures involved, including the medial crura of the lower lateral cartilages, the septal cartilage, the anterior maxillary spine, the fibrous tissue supporting the se cartilages, and finally the muscles of the base of the nose (Fig. 26.1).

Residual Deformities of the Ala

The alar rim must have a harmonious line - not too low, not too high, not too straight, and not asymmetrical. When the relationship between the columella and the alar rim is not an aesthetic one, or when the nose has been significantly shortened by raising the columella, it may be necessary to raise the alar rim.

Residual Deformities of the Dorsum

Saddle nose is one of the most common nasal deformities. The origin of saddle nose can be congenital- a familial or racial characteristic - or acquired. The acquired forms can be luetic, traumatic, or iatrogenic. Traffic accidents, boxing, gymnastics, ball garnes,and winter sports are primarily responsible for traumatic occurrences. Unfortunately, postoperative saddle noses are rather common. They are seen after septal resection when cartilaginous support is poor underneath the weak triangle of Converse at the lower end of the upper lateral cartilages. The most common cause of saddle nose following primary rhinoplasty is weakening with subsequent collapse of the cartilaginous septum after an extensive septal resection.

Intranasal Endoscopy as Treated by D. Simmen

With the introduction of nasal endoscopes we gained a very important additional instrument for use in diagnosis, but also an important advantage in the treatment of specific septal deformities. These pathologies can be operated on with endoscopic guidance in the course of minimally invasive aesthetic nasal surgery, improving nasal breathing significantly. Abasal cartilaginous septal spur (Fig. 21.1) can be exposed by an incision along the nasal floor.A raspatory is then used to mobilize the mucosal flap posteriorly into the bony portion. With a knife the extent of cartilage is resected by an incision along the premaxillary crest as an inferior chondrotomy. Again by means of the raspatory, under endoscopic guidance, the cartilaginous spur is luxated away from the bony crest. If necessary, a bony portion of the premaxillary crest can also be removed using a 2-mm chisel.

Residual Bony Deformities

Up to this point I have discussed immediate and early pitfalls. Residual deformities arising after primary rhinoplasty not stemming from those complications already discussed are due to errors in the conception of the surgery, errors in planning the different steps of the intervention, technical faults, and unpredictable and uncontrollable pitfalls and vagaries in the postoperative healing process. I will analyze and discuss these faults and pitfalls and the unfavorable results that follow them, and also the techniques with which it might be possible to avoid them and to correct them in secondary procedures. Toprepare the wayfor this, I would first like to explain the different steps of both primary and secondary operations.

Stenosis and Atresia

The treatment of stenosis and atresia of the nose is an important task,because the human being requires a free nasal airflow for the benefit of physical balance. The site of stenosis can be in any of three parts: (1) vestibule, (2) nasal cavity, and (3) choana. It can be unilateral or bilateral and ranges from slight to severe.

Nasolabial Angle and Upper Lip

The transfixion incision is very helpful when the major changes needed in the tip-columella-lip complex have to be made. Through this incision I can vary the relationships between tip projection, the infratip region, columella angulation, the columello-labial junction, the central upper lip slope, the central upper lip prominence, and the position of the central lip-free border. The relationships and structures involved are what Webster (1975a,b) calls the “tip-columella-central upper lip aesthetic complex.”

Pointed Narrow Tip and Bifid Tip

The pointed narrow tip results when the entire dome of the lower lateral cartilages, including the vestibular lining, has been excised during the primary procedure. The treatment of this deformity often requires more than just a trapezoid or triangular strut. The acute angles formed by the residual stumps of the lower lateral cartilages have to be trimmed secondarily, and in most cases the nose should also be shortened. The medial segments of the lateral crura are spread and a suitably formed piece of cartilage is interposed between them, producing a smooth, broader, and more rounded tip.

Nasal Valve Collapse

The etiologies of nasal airway obstruction are septal deviation, turbinate hypertrophy, broad columellar base, excessively high vestibular floor, and position of the mobile lateral wall of the nose. The last is known as collapse at the valve, which can be an anterior (i.e., alar) collapse, a posterior (i.e., middle third) collapse, or both. Using different terminology, Constantian (1994) distinguishes between external and internal valvular incompetence.

Open Procedures as Used by J.-F. Emeri

The essence of this technique is to shape the cartilage and bone under maximal direct vision and rebuild support into the nose. Very little of the nasal skeleton is removed. Grafts and suturing techniques are combined with conservative trimming of the cartilage and bone.