CURRENT THOUGHTS & PREVENTING COMPLICATIONS
CURRENT THOUGHTS & PREVENTING COMPLICATIONS
I hope you get this letter. You have witnessed and experienced a new concept of rhinoplasty far from conventional methods during our Preservation Rhinoplasty Course 29 November-1 December 2018, in Istanbul. We will be more than happy to hear that you obtain good results with this new technique but also feel responsible for possible complications. Therefore, we are sending you a brief explanation of the technique together with a list of some points you should pay attention to avoid complications. Please read carefully.
Many surgeons consider Preservation Rhinoplasty (PR) and Dorsal Preservation (DP) to be the same entity, they are not. Dorsal Preservation is retention of the natural dorsum while eliminating the hump and lowering the nasal profile. DP is one part of the three parts of Preservation Rhinoplasty. Also, many surgeons have wondered how they can do the surgery without Piezo electric or power instruments. The following are some suggestions for using conventional surgical instruments.
Obtain the right instrumentation for subperichondrial dissection. Make sure to start your dissection at the right point. Otherwise tip cartilages may be injured and you will be upset. Please refer to this paper in ASJ A complete subperichondrial dissection technique for rhinoplasty with management of the nasal ligaments. (https://www.ncbi.nlm.nih.gov/pubmed/22745445). You can also study the Preservation Rhinoplasty book. You can view the endoscopic dissection videos in the Karma Rinoplasti Application in Appstore.
Correct instruments are also important for dorsal preservation. You can refer to the article by Yves Saban Dorsal Preservation: The Push Down Technique Reassessed. (https://www.ncbi.nlm.nih.gov/pubmed/29319787) , and also the relevant chapters in the Preservation Rhinoplasty book.
Cartilage Septum – curved scissors, angled straight septal scissors
Bony Septum – small rongeur ( Storz #200600)
Lateral Osteotomy – 3- 4mm Gubisch-Fanous
Transverse Osteotomy – Taştan-Çakır saw or 2mm Gubisch osteotome
Radix Osteotomy – Taştan-Çakır saw or 2mm Gubisch Osteome
( A note about use of hand saws. Based on cadaver work and intraop endoscopic views, it is obvious that hand saw work quite well…clean definite cuts. However, they do require resistance and thus most surgeons do their transverse and radix osteotomies before the lateral osteotomy as the lateral osteotomy creates too much mobility and decreases resistance)
B. Operative Sequence:
The exposure will vary dramatically depending upon the surgeon’s preference for an open or closed approach as well as the desire to protect the nasal ligaments.
a. Septal Exposure. In general, most surgeons should use whichever exposure technique they routinely perform. Obviously, there must be adequate tunnels bilaterally beneath the dorsal septum to allow resection, both vertically for instrument insertion, and longitudinally back over the PPE.
b. Dorsum / Bony Vault. In general the dorsum is exposed in a subperichondrial plane over the cartilaginous dorsum and subperiosteal over the bony dorsum extending into the radix area. The key variable is the amount of dissection over the lateral bony wall – limited if traditional osteotomes will be used, wide degloving for Piezo or hand saws. For osteotomes, a subperiosteal lateral tunnel is made along the nasofrontal groove and passes under the superficial limb of the MCL. Note: the maxillary side is undermined when greater descent of the bone is required as for an asymmetric “push over” procedure.
Perform the septoplasty first. Do not perform the let-down or push-down procedure with L-septoplasty. After a strip of cartilage is removed from the septal base, secure the septum to the periosteum and perichondrium posterior to the maxillary spine and place Doyle splints at this stage. Thus, the septum will be more stable when removing bone from the PP.
3. Septal Strip Excision:
It is important to understand both the “W-point” and the “W-ASA” segment. The “W-point” is where the caudal segment of the ULC separate from the dorsal segment. The “W-ASA” segment is the distance from ASA to W point and is often 8-10mm. Most commonly, a 2-3mm strip of cartilage is removed from the subdorsal septum (set aside for struts) and then the bony portion of PPE is removed. Additional cartilage is removed if more lowering is required and more bone if blockage occurs.
a. Cartilage. The cartilage excision begins at the “W-point” not at ASA. Angle scissors are used to allow one to make the line of incision cut just below the dorsum and follow its contour. Be aware that the relationship between the osseocartilaginous dorsal junction (Rhinion – R point) on the surface and the underlying junction between cartilaginous septum and PPE is often 0-12mm difference, probably with a mean of an 8mm cephalic difference. Next, the line of excision cut is made approximately 2-3 mm below the initial cut, preferably with a small downward curve. Then an elevator is used to break any connection at the PPE junction and the cartilaginous strip is removed.
b. Bone. Elevate the radix mucosa prior to excising bone. Otherwise you may have excessive bleeding from the mucosa. The most dangerous zone in the dorsal preservation technique is where you remove a bony strip from the perpendicular plate. When removing this strip, bone may be mobilised especially in the elderly. Please do not perform this surgery without a rongeur of 2mm tip width. A sharp small rongeur is used to “nibble” the bone out just below the dorsum, from the cartilaginous septum / PPE junction cephalically toward the Nasion or the level of the future radix osteotomy. It is critical that these be small sharp bites (fingernail clippings) and not large twisty bites which could lead to a fracture into the cribriform plate. One should carefully measure the progress cephalically with the rongeur in place and then against the skin surface. Make sure that the bony excision from the perpendicular plate goes beyond the transverse radix osteotomy line. Otherwise the mobilised bony vault may press on the perpendicular plate and mobilise it. Note: The bony septal excision is always done before the radix osteotomy to avoid unwanted radiating fracture lines into the cribriform area. Please don’t use chisel and hammer to remove bone from Perpendicular plate of ethmoid. Please be aware that, although very rare, you may have CSF leakage with this technique. It is wise to question for previous head trauma. Even a normal nasal discharge will put the surgeon under stress. CSF test may be performed from the discharge.
4. Lateral Osteotomy:
One of the more recent evolutions has been a blurring of the differences between a “Push Down” and a “Let Down” technique. It would appear that in most cases, the lateral walls are inside the pyriform aperture to a variable degree and thus there is a “push down” component rather than a “let down.” If you are using chisels like Yves Saban, you should do the lateral osteotomies first. But if you are using handsaws, you may prefer to do the lateral osteotomies at the end.
a. Webster’s Triangle Excision. The Webster’s triangle is removed in virtually all cases – often 5mm in height by 8mm in length. It can be done with a rongeur. Obviously, the mucosa is elevated on both sides of the area prior to removal. Note: all bone removed is saved and can be used as a radix graft if necessary.
b. Low-to-Low Osteotomy. In general, a straight 3-4mm osteotome is used in an angulated (sagital – vertical) position placed in the nasofacial groove. The length of the osteotomy is surprisingly short as 8mm of bone has been removed with the Webster’s triangle excision. The cephalic extent will pass beneath the MCL to the level of the anticipated transverse osteotomy. Note: there is a certain question as to the orientation of the lateral osteotomy – transverse-angulated- vertical. In general, a more angulated osteotomy is done as it allows the lateral bony base to move into the pyriform aperture. Also, the location is at the nasofacial groove which is significantly lower than the classic Sheen low to low osteotomy. Midlevel lateral osteotomies may be preferred in patients with an already narrow base.
5. Transverse Osteotomy:
The transverse osteotomy connects the low-to-low osteotomy with the radix osteotomy – thus these 2 points can be marked at the beginning of the operation. However, one should plan on the transverse osteotomy stopping at the ipsilateral dorsal line and not going onward to the midline. The simplest way to do the transverse osteotomy is with a 2mm osteotome. Other surgeons will prefer to use a Taştan-Çakır hand saw which is done with a “screwdriver” twisting motion. If using the hand saw the transverse osteotomy should always precede the lateral osteotomy as the bone needs to be stable during this maneuver. Others, will prefer to mark the bone with the saw first and then follow this superficial cut with the osteotome.
6. Radix Osteotomy:
Currently, the radix osteotomy is one of the two most controversial maneuvers in DP surgery. The first controversy is location of Nasion. From numerous studies, we know that the nasion point (N) in the radix area is 4.9mm above the MCL (level) and clinically it often corresponds to the lash line. For the vast majority of noses, N is not changed as regards its level. The height, relative to a vertical line adjacent to the glabella, may need augmentation. The variation among surgeons is that most surgeons want to maintain the N point 3-5mm above the MCL, some at the MCL (which is lowest point on pupil), and a few below the MCL. Note: the lower the level of the Nasion, the longer the radix area becomes and the more “infantile” the nose. The second question is how should the osteotomy be done and to what degree. Typically, the radix osteotomy is done with a 2mm percutaneous osteotome positioned in a cephalic caudal direction. A central cut is made in the bone and then “walked over” to meet the two transverse osteotomies. Some surgeons prefer to use the Tastan-Cakir radix saw in a side sweeping motion, either for a complete cut or to mark the bone first before using a 2mm osteotome. Ultimately, the cut must go through the fused nasal bone pyramid, nasal spine of the frontal bone and enter the resected space of the PPE.
7. Disarticulation / Movement / Impaction:
It is generally accepted that there must be complete separation of the nose from the skull. This total separation is confirmed by horizontal mobilization of the bony vault from right to left. Any restrictions must be released. Next, the bony vault is pinched and pushed down to achieve the desired lowering. The second controversy is what type of lowering: hinge vs downward displacement. Essentially, some surgeons feel that in the predominately cartilaginous nose with limited change in N, then a more controlled fracture at the Nasion and lowering of the dorsum, ;i.e. a hinge reduction of the nasofacial angle is the preferred method. Alternatively, in major bony humps and the full radix, a complete cut through the radix area followed by disarticulation- descent will produce the desired change. The disadvantage of this maneuver is that it creates a 2-3mm step at the radix osteotomy site which requires either a bony reduction and or a camouflage radix graft. For most noses, it is best to begin with a graded hinge movement and progress to disarticulation-descent as needed.
8. Evaluation / Adjustment:
Once the dorsum has been lowered, then minor adjustments are made. It may be necessary to remove additional septal cartilage strips and on occasions minor portions of PPE to achieve the desired level. If more flattening of the hump is desired, small vertical cuts are made in the septal strip remnant just below the dorsum. Further flattening can be achieved by a bilateral “LKA release” – essentially cutting the fibers between the nasal bone and the ULC in the Lateral Keystone Area. This maneuver allows the osseocartilaginous hump to flex downward beneath the keystone area. Note: the W-ASA segment is retained until the final profile alignment and then it is tapered to fit the profile – its retention minimizes the chances of an intraoperative saddle.
Most surgeons fix the mobilized dorsum to the septal pillar. For those doing a closed approach, 2 sutures are often used. A cerclage type of suture at the keystone are beginning on the septum, out through the cartilage vault, back through the opposite cartilage vault and the tie placed on the septum. An alignment suture is placed in the perichondrium beneath the caudal border of the ULC on either side and then tied in the midline. This suture keeps the septum in the midline. If one has done an open approach, then a 3 point fixation as advocated by Kosins is used. Suture #1 is placed at the original K-point of the hump. Small drill holes are made through the bone on either side (most often these holes are placed at the start of the case). A 4-0 PDS suture is passed through one hole, then across the dorsal septum, out the opposite bone hole and then tied in a cerclage fashion. The goal is to keep the dorsum flat and resting against the septum thereby minimizing the chance of a recurrent hump. Suture#2 is placed at the W-point with 5-0 PDS. Since the distal cartilage vault is still mobile, certain adjustments can be made. The steps are as follows: 1) the vault is moved from side to side till the best location is found, 2) the vault is then fixed to the underlying septum with a #25 needle, and 3) the suture is then inserted to stabilize the structures in the correct position. Suture # 3 is inserted midway between the other two sutures using a 4-0 PDS suture passed in a cerclage fashion. Essentially, one has locked down the dorsum in the desired position and fixed it at 3 points.
We will be in Nice www.preservation-rhinoplasty.com meeting on February 2-3 2019 and Roma Preservation Rhinoplasty meeting on September 2019. Preregistration going to be open soon on www.preservationrhinoplasty.com web site. Also you can order the preservation Rhinoplasty book from the website.
With our best regards on behalf of the organizing committee and faculty of Preservation Rhinoplasty Course Istanbul 2018
Rollin K. Daniel, Yves Saban, Barış Çakır, Peter Palhazi