Complications of Rhinoplasty - Page 11

THE NASAL VAULT
(MIDDLE AND UPPER NASAL THIRDS)

General Considerations
The aesthetic importance of the nasal profile and the tipsupratip relationship makes profile reduction a critical step in rhinoplasty. Overreduction of the bony component may lead to a flattened appearance that simulates pseudohypertelorism. Overreduction of the bony and cartilaginous nasal vault results in an overly concave, operated appearance. Overreduction may lead to iatrogenic saddle-nose deformity. While undertaking profile reduction, great care must be taken to preserve support of the middle nasal vault; failure to do so can lead to complications such as nasal valve collapse and inverted-V deformity.

Prevention of over- or underresection requires knowledge of skin thickness and the anatomical contributions of bone and cartilage to the nasal dorsum. The bony contribution of the nasal dorsum is less than that of the cartilaginous structures; great care must be taken in the resection of each component. The skin/soft tissue envelope is thicker over the nasofrontal angle and the supratip region and thinnest over the rhinion. Less hump is taken at the rhinion to accommodate this.

Underreduction leads to a persistent deformity. Underre­ duction may not only leave a persistent dorsal hump but may also create a supratip prominence or pollybeak, or, alternatively, an unsightly prominence at the upper nasal third. Nevertheless, this deformity is preferable to overreduction because it is easier to correct the underreduction secondarily when indicated.

Asymmetrical resection may lead to an unsightly appear­ ance. Correction of this deformity is challenging. This may be accomplished with onlay grafts, either through a precise pocket placement or via an external rhinoplasty approach.

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