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A New Technique for Reconstruction of the Nasal Dorsum
Underlay Autografting
Farahmand Sabeti, MD;
Abbas Nadimi Tehrani, MD
Arch Facial Plast Surg. 2002;4:141-148.
ABSTRACT
This article presents a new surgical technique for reconstruction of
the nasal dorsum following excisional rhinoplasty in patients with prominent
humps. Reinsertion of the excised hump is not a new concept. Rather, underlay
grafting of the resected hump was developed by modification of the Skoog technique,
addressing the problem by salvaging the upper cartilaginous vault.
INTRODUCTION
Following excision of the nasal dorsum and infracture of the lateral
walls in patients who require removal of a prominent hump, breakage of aesthetic
lines may occur because of caving in of the osteocartilaginous junction. The
natural width and roundness of the dorsum are frequently lost. Any irregularities
of the dorsal line may become evident and the camouflaging effect of the dorsum
on minor twists of the anterior septum may be eliminated. Excessive removal
of the upper lateral cartilages and septum in an attempt to lower the dorsum
leads to middle vault collapse, narrowing the internal valve area, and predisposing
the patient to impairment of nasal airflow. Patients with narrow nose syndrome
are especially susceptible to middle vault collapse. Others may have a propensity
for middle vault collapse because of short nasal bones, weak nasal cartilages,
thin skin, or a combination of all of these.1-2
The role of the special anatomy of the upper cartilaginous vault in maintaining
the smooth confluence of osseous and cartilaginous vaults and supporting the
internal valves also merits special consideration. This article presents a
new surgical technique for reconstruction of the nasal dorsum following excisional
rhinoplasty in patients with prominent humps. Reinsertion of the excised hump
is not a new concept. Rather, underlay grafting of the resected hump was developed
by modification of Skoog's technique, addressing the problem by salvaging
the upper cartilaginous vault.
OPERATIVE TECHNIQUE
Endonasal transcartilaginous incisions were made and united to a bilateral
transfixion incision. The skin and soft tissues overlying the cartilaginous
vault were elevated in a submusculoaponeurotic plane by fine-pointed scissors.
The periosteum over the median nasal bones was elevated using a Joseph elevator.
Using an extramucosal approach, the mucosa was reflected downward from the
undersurface of cartilaginous and osseous vaults. At the anterior border of
septum, this mucosal undermining was a few millimeters more than the designed
resection of septum. The mucosal undermining extended inferiorly approximately
twice the estimated distance of the dorsal reduction under the upper lateral
cartilages and nasal bones (Figure 1).
After cutting the designed portion of the cartilaginous hump with scissors
or a No. 11 blade, the osseous hump was resected in continuity with the cartilaginous
hump using a 12-mm osteotome. Then septoplasty or tip refinements were performed
as outlined in the operative protocol. The excised hump, preserved in a gentamicin
sulfate–containing isotonic sodium chloride solution, was then sculpted.
Using a No. 15 blade, the resected septal part of the hump was removed with
a fine blade (Figure 2). Special
attention was paid not to thin excessively the 1- to 1.5-mm-thick septum intervening
the upper lateral cartilage remnants. This septal part made an integrated
single unit with the upper lateral cartilage remnants and was the essential
ingredient of integrity and springlike action of the graft. After careful
separation of the lateral-most portion of the upper lateral cartilage remnants
attached to the undersurface of the osseous hump, the lateral border of the
osseous hump was trimmed down to a slender triangular bony segment attached
to the cartilaginous part of the graft with a fine bone cutter (Figure 2). Excessive thickness or convexity of the osseous part
could be carefully rasped and flattened. Alternatively, the upper portion
of the resected hump could be modified by first separating the cartilaginous
vault completely from the undersurface of the bony hump, and then crushing
the upper most portion of it by a small needle holder (Figure 2). Before inserting the graft and after confirming the adequate
lowering of the dorsal profile, another 1 to 1.5 mm of anterior septum was
resected to compensate for the graft thickness. By applying a thin Aufricht
elevator, the dorsal skin and soft tissues were elevated. The graft was applied
over the open roof, with the triangular bony fragment or the crushed upper
part of the graft lying over the open bony roof. The caudal upper lateral
cartilage remnants were then laid out and held lateral to the anterior border
of the septum with a nontooth Atson forceps near the septal angle. The graft
was fixed to the septum in this position by 1 or 2 nonabsorbable 5-0 horizontal
mattress sutures in the caudal third. Mattress sutures automatically drove
the lateral wings of the graft toward each other at an almost 120° angle
slipping under the remaining upper lateral cartilage edges that were appropriately
denuded of mucosa (Figure 3). If
there was any suspicion of the exact underlying positioning of the graft,
the lateral portions of the graft could be sutured deep to the upper lateral
cartilages by fine absorbable sutures. After graft placement, low to high
lateral osteotomies were made. The endonasal incisions were repaired and the
nose was splinted.
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Figure 1. Extent of mucosal dissection in
different levels of the nasal framework: A, lower bony vault; B, upper cartilaginous
vault; and C, lower cartilaginous vault. Note the extent of mucosal undermining
under the upper lateral cartilages.
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Figure 2. Preparation of the graft is done
by first removing the septal remnant (A) and then either trimming the lateral
borders of the osseous hump over the underlying upper cartilaginous vault
(B) or removing the osseous part and crushing the uppermost portion of the
graft (C).
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Figure 3. The final position of the graft
(left) before doing lateral and medial osteotomies. The cross section of the
nasal skeleton (right) demonstrates the graft position in the lower bony vault
(A), upper cartilaginous vault (B), and lower cartilaginous vault (C).
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RESULTS
Fifteen patients (12 women and 3 men) with prominent nasal humps underwent
primary excisional rhinoplasty by the described operative technique. The age
of the patients ranged from 18 to 38 years. After the initial study, the technique
was used for an additional 10 patients whose follow-up period is still less
than 18 months. All of the patients needed dorsal profile reduction exceeding
3 mm in the area of osteocartilaginous junction. In 8 patients, including
3 who did not undergo lateral osteotomies because of exceedingly narrow bony
arch, the graft contained a slender osseous segment. In the remaining 7 patients
the graft did not have any bony portion. Several other procedures such as
septoplasty, tip surgery, or alar wedge resection were performed on most of
them. After at least 18 months of follow-up, there was no incidence of immediate
or late infection, hemorrhage, or displacement of the graft. None of the patients
needed intraoperative or postoperative graft removal. Physical examination
also showed no evidence of graft palpability, mobility, or resorption. There
was no evidence of middle vault collapse, open roof, adhesion, or fibrosis
of the skin and soft tissues. Smooth confluence of the bony and cartilaginous
vaults was observed on frontal and lateral views. The curvature of the cartilaginous
vault was preserved and excessive broadness was not evident in any of the
patients (Figure 4, Figure 5, and Figure 6).
Two patients showed a little protuberance of the osteocartilaginous junction
on the profile view, which was due to inadequate lowering of septum to compensate
for graft thickness (Figure 6).
Another patient had evidence of inadequate lowering of the dorsum in the supratip
area. The main complication, which was universally observed, was prolonged
postoperative edema of the middle vault area that lasted about 2 to 3 months.
None of the patients reported any change in airway competence either during
exertion or at rest, although objective assessment by rhinomanometry was not
performed.
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Figure 4. Preoperative photographs (A, C,
and E) of a 24-year-old patient with a large deviated nose and large skin
sleeve. Postoperative photographs (B, D, and F) 2 years after hump excision,
lateral osteotomies, and underlay grafting of dorsum. The smooth confluence
of bony and cartilaginous vaults and the natural appearing dome-shaped middle
vault is noted postoperatively.
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Figure 5. Preoperative photographs (A, C,
and E) of a 33-year-old patient with a high nose and relatively narrow bony
base. Postoperative photographs (B, D, and F) 18 months after osteotomies
and underlay grafting of dorsum.
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Figure 6. Preoperative photographs (A, C,
and E) of a 25-year-old patient with a large nose and asymmetric bony walls.
Postoperative photographs (B, D, and F) 18 months after hump excision, tip
sutures and grafting, multiple osteotomies of the right side, and underlay
grafting of dorsum. On the profile view, a small protuberance was noted that
was due to inadequate lowering of dorsum to compensate for graft thickness.
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COMMENT
The peculiar anatomy of the nasal dorsum should be taken into consideration
in any surgical procedure in dealing with reconstruction of nasal dorsum following
excisional rhinoplasty. The nasal dorsum is a curved and arched structure
that is widest in the rhinion area and narrowest in the intercanthal area
and internal valve area of nose. Resection of a large hump and infracture
of the lateral walls greatly reduce this difference in width, and the resulting
open roof can never be closed completely (Figure 7). On the other hand, the upper cartilaginous vault normally
has a curved and dome-shaped appearance that changes to a flat-shaped structure
in classic excisional rhinoplasty. Even using spreader grafts may not restore
the natural contour over a flattened dorsum after resection of the hump. Rhinoplasty
surgeons often experience satisfactory results by preserving the integrity
of the nasal mucosa and avoiding excessive resection of the upper lateral
cartilages and septum in patients with relatively small humps and average
skin thickness. In fact, minimal reduction of the dorsum in the rhinion area
reduces the medial tilt and movement of lateral walls after doing osteotomies
and the remaining septum and upper lateral cartilages would retain much of
their thickness and strength, greatly diminishing the incidence of middle
vault collapse. On the other hand, patients requiring resection of a prominent
hump frequently need some sort of graft to prevent middle vault collapse.
Different surgical procedures have previously been applied to reconstruct
the nasal dorsum.
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Figure 7. Excision of a prominent hump (A)
and infracture of lateral walls to close the open roof greatly diminishes
the difference of dorsal width in the rhinion, intercanthal, and valve regions
(B).
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REVIEW OF THE LITERATURE
Cottle, in 1954, was the first surgeon who proposed autografting the
nasal dorsum after its excision; however, it was Skoog who performed it routinely
in rhinoplasty operations. Cottle also introduced pushdown rhinoplasty, which
did not solve dorsal convexity besides being a difficult procedure.3
In 1966, Skoog4 described a series of
19 patients who, based upon the Cottle concept, underwent nasal hump removal
and reinsertion after trimming of the lateral borders and excising the septal
remnant. He pointed out that after separating the septal remnant, the excised
hump would invariably convert to a straight graft. He also emphasized that
reinsertion of the dorsum would prevent a "surgical" appearing nose.4-5 Regnault and Alfaro6
applied Skoog's technique extramucosally in a series of patients. By applying
this technique, the graft was completely separated from the nasal cavity.
The hump acted as a true autograft and theoretically would be revascularized.
Skoog's technique had some disadvantages. A large hump required intact removal;
if considerable fractures occurred in its osseous part, it could not be used.
The graft was occasionally unstable and mobile in some patients. The authors
applied Skoog's technique in some patients and noted undesirable postoperative
excessive broadness of dorsum in most of them. The broadness probably has
resulted from the strong tendency of the cartilaginous vault, being disconnected
from the remaining nasal framework, to splay.
Daniel described another technique in which the nasal dorsum, while
still attached to dorsal skin and soft tissues, was elevated by cutting the
septum and upper lateral cartilages in predetermined locations. Based upon
the previous measurements, the dorsal height was then reduced and finally
the elevated roof was fixed on the new dorsum.7-9
He reported that the recapitulated roof could operate as a spreader graft
and could camouflage the underlying irregularities. Daniel's technique had
the same rationale as Skoog's technique; however, the nasal dorsum was separated
in a critical point from the nose and necessary refinements were performed
not on the hump, but on the remainder of the nose. The technique, in addition
to being useless if any significant fracture occurred in the bony hump, shared
some disadvantages of Skoog's technique. Furthermore, the surgeon could not
manipulate the dorsal surface of the hump.
Sheen presented a technique in 1983 that was based on using strips of
septal cartilage along the anterior border of the septum to increase middle
vault width following excision of the dorsum.1-2
This technique kept the upper lateral cartilages farther from the septum,
decreasing the likelihood of internal valve constriction. He recommended middle
vault reconstruction in all primary rhinoplasties that included removing the
cartilaginous vault. Sheen pointed out that the main factor that should be
restored was the sufficient width of anterior septal border, which spread
the upper lateral cartilages. Although application of the spreader grafts
has been the dominant technique used by surgeons to reconstruct the middle
vault, the author's experience has been in accordance with Guyoran et al's
notification that these grafts result in variable functional success while
the aesthetic outcome is often gratifying.10
McKinney and colleagues used a thin septal cartilage graft, which was
sanded and shaped as a shield to close an open roof.11-12
It was claimed that the graft covered underlying irregularities, camouflaged
any residual twist of septum, and acted as a spreader graft. The technique
necessitated using a relatively long (about 35 mm) and wide portion of the
vital septal cartilage.
Guyoran et al10 developed upper lateral
splay grafts to reconstruct the natural confluence of upper lateral and septal
cartilages in secondary rhinoplasty patients with middle vault collapse. The
splay graft spanned the dorsal septum but was laid deep to the upper lateral
cartilages. It was reported that the graft induced functional improvement
in all of the patients operated on but could result in excessive widening
of the caudal portion of the dorsum.
THE NEW TECHNIQUE: UNDERLAY AUTOGRAFTING OF DORSUM
The new surgical technique relies on using the patient's excised hump
for reconstruction of the nasal vault to prevent middle vault collapse and
preserve the natural contour of the middle third of nose. The main difference
of the present technique with the previous ones is the attempt to reconstruct
the springlike T-junction of the upper lateral cartilages and septum in the
upper cartilaginous vault and to prevent the occurrence of excessive broadness
of dorsum.
Considering the functional anatomy, there is an important difference
between the upper and lower cartilaginous vaults.13
McKinney et al11 demonstrated that the upper
two-thirds of the cartilaginous vault consists of the upper lateral cartilages
and septum as an integrated single unit, but in the lower third of the vault,
the cartilages are usually separated from the septum and are only attached
by fibrous connections. The upper cartilaginous vault gradually thickens and
strengthens cephalically and variably extends under the nasal bones. The special
anatomy of cartilaginous vault has important functional and aesthetic implications.
The cartilaginous dorsum width naturally increases toward the rhinion area
and the T-shaped springlike upper cartilaginous vault takes on an arched,
domelike configuration (Figure 8).
The spring inherent in the T-shaped junction splays out the upper cartilaginous
vault under the bony arch (Figure 9).
Separation or attenuation of the junction in the lower vault makes the nasal
framework more collapsible by internal negative pressure and has a significant
role in permitting the caudal border of upper lateral cartilages to act like
a valve during inspiration and regulate the airflow through the nose (Figure 9). Guyoran et al10
reported that strengthening the upper cartilaginous vault by an underlying
splay graft improved airflow through the internal valves postoperatively in
secondary rhinoplasty patients suffering from middle vault collapse. Their
study may support the contention that the spring of upper cartilaginous vault
is the key element in the structural support of internal valves although Sheen1-2 has previously implicated anterior
septal width in valve support.
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Figure 8. Schematic representation of a
cross section of the upper, middle, and lower cartilaginous vault (A, B, and
C) and the corresponding levels of the excised hump (D, E, and F). Note that
the hump lies completely flat, which could be compared with the freeing of
a spring.
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Figure 9. Schematic representation of the
nasal framework. The cartilaginous vault could be compared with a springlike
plate (A), which is restricted by its connections to the bony arch (B). C,
Breakage of the T-junction in the lower vault renders it a compressible valvelike
structure. D, The condition that results from classic excisional rhinoplasty.
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The peculiar dome-shaped structure of middle vault also provides the
nose with maximal inner space and maximal tension on the skin (Figure 10). This is why excision of the dorsum induces a greater
increase in the skin sleeve than what is expected from dorsal height reduction.
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Figure 10. Cross sections of a tent model
for upper cartilaginous vault structure to demonstrate the effect of different
vault shapes on the available inner space and tension on the drape. Model
corresponds to an operated-on nose by excision of dorsum and infracture of
lateral walls (A), to the reconstruction of dorsum by spreader grafts (B),
and to an unoperated-on nose or reconstruction by underlay grafting (C).
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Underlay autografting of dorsum has been applied using a closed rhinoplasty
technique, although graft placement could be obviously more convenient should
an open approach be used. Graft sculpting was similar to the Skoog technique
with a few important differences. The hump was not excised more than the desired
reduction of dorsal profile and the upper lateral remnants of the hump were
not trimmed. Marked lateral trimming of bony hump was done after careful freeing
of its lateral borders over the cartilaginous dorsum (Figure 3). In 7 patients the graft was sculpted by completely removing
the bony segment, preserving the cartilaginous dorsum and crushing its cephalic
portion. The latter procedure enabled us to use the excised hump despite inadvertent
fractures of the osseous portion. Both procedures yielded almost equally satisfactory
postoperative results. On palpation, however, the group having the graft with
a small bony segment showed better coverage of the bony roof. Three patients
with exceedingly narrow, high noses did not undergo lateral osteotomies. The
graft also worked well in them by a suitably covering the open roof and maintaining
airway competence.
The satisfying postoperative aesthetic and functional results and the
low rate of complications indicate the new technique to be predictable and
reliable. In addition, the present technique has several advantages. First,
positioning of the graft incorporates it to the nasal framework and splays
the upper lateral cartilages to avoid middle valve collapse. Second, the graft
is predominantly invisible and its lateral borders could not be identified
on inspection or palpation. Third, it may provide the surgeon more safety
in doing lateral osteotomies in patients with relatively narrow bony bases
(Figure 5). This is also true in
patients with short nasal bones and wide bony bases. The patient need not
necessarily have a very large hump and the procedure could be accomplished
in any patient who need at least 3-mm dorsal reduction in rhinion area. The
underlay positioning of the graft camouflages any asymmetry of the lateral
cartilaginous wall resection and inevitable fine irregularities of dorsal
septum. It also provides maximal dimensions to the nasal framework, opposing
skin thickening and deformity. The technique does not obligate septal surgery
for graft harvest and vital septal cartilage is spared.
The disadvantages of the technique are as follows: First, many surgeons
may be unfamiliar with the technique. Second, since the hump is necessarily
excised as a single unit and preserved temporarily out of the patient's body,
inadvertent loss of it might occur. Third, the technique does not correct
a wide or asymmetric dorsum. Finally, long-term follow-up of this technique
is not yet available.
AUTHOR INFORMATION
Accepted for publication May 9, 2002.
This article was presented at the Spring 2001 Meeting of American Academy
of Facial Plastic and Reconstructive Surgery, Palm Desert, Calif, May 11-12,
2001.
We gratefully acknowledge Wayne F. Larrabee, Jr, MD, for help in preparing
the manuscript; Sam Most, MD, for excellent editing assistance; and Barbara
Stackhouse for contributing the illustrations.
Corresponding author and reprints: Farahmand Sabeti, MD, No. 19,
Unit 6, First Alley, Behrooz Street, Mohseni Square, Mirdamad Street, Tehran,
Iran (e-mail: drsabeti64{at}yahoo.com).
From the Departments of Otolaryngology–Head and Neck Surgery,
Islamic Azad University (Dr Sabeti), and Tehran University of Medical Sciences
(Dr Tehrani), Tehran, Iran.
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