Overresection and Saddle Nose
Saddle nose refers to the appearance of the nose after loss of support of the nasal vault with subsequent collapse (Fig. 18-10). This deformity has been described after overresection of the septum with failure to preserve an adequate L-strut. A minimum of 15-mm of cartilage is recommended as a rule of thumb: if a dorsal hump resection is also planned, this must be accounted for in planning adequate L-strut for nasal support. Other causes of saddle nose deformity include septal hematoma, septal abscess, and severe nasal trauma. Excessive dorsal hump resection also leads to saddle nose deformity.
Onlay grafting can effectively camouflage and correct mild and moderate saddle deformities (Fig. 18-10). Single or multiple layers of septal cartilage or auricular cartilage are commonly used effectively.30,31 Severe saddle nose deformity may require major reconstruction with cantilevered cartilage or bone grafts.32,33
Precise pocket grafting can be effectively used when this is an isolated problem (Fig. 18-10). The pocket is dissected over the anterior septal angle via bilateral limited marginal incisions. Bilateral incisions are used to ensure symmetry of the pocket so that the graft will lie straight. Asymmetric dissection of the pocket can be a cause for graft shifting.
When a patient has thin skin, AlloDerm (LifeCell, Branchburg, NJ) may be used to provide some additional cushion. Although it appears that this may provide some lasting benefit, the long-term fate of AlloDerm is unknown (Fig. 18-11).
My experience with alloplasts has been to remove them because they cause pain or an unacceptable cosmetic result, they became infected, and they extrude into the nose and also through the skin. There is disagreement within the field of rhinoplasty regarding the use of alloplasts. It is my feeling that the nose fulfills few of the requirements for use of alloplastic materials. If the alloplasty extrudes through the skin, the skin-soft tissue envelope is permanently and irreparably damaged. I discourage the use of Alloplasts in both primary and revision rhinoplasty.
Inverted-V-Middle Vault Collapse
In this deformity, the caudal edge of the nasal bones is visible in broad relief. Inadequate support of the upper lateral cartilages after dorsal hump removal can lead to inferomedial collapse of the upper lateral cartilages and an inverted-V deformity.34 Inadequate infracture of the nasal bones is another significant cause of inverted-V deformity. The anatomic cause of inverted-V deformity must be identified and addressed. Osteotomies with infracture of the nasal bones, spreader grafts, or both may be required.
Twisted Nose: Newly or Persistently Twisted
Persisting deviation after rhinoplasty may occur at the upper third, middle third, or tip of the nose or may occur postoperatively in a previously straight nose. Preoperative anatomic diagnosis is a critical component of successful treatment. Persisting deviation of the nasal bones may occur because of greenstick fractures or other problems with osteotomies.35,36 Inherent deviations in the cartilage of the middle nasal vault may prove especially challenging. 36 In addition, hump removal may uncover asymmetries that result in postoperative deviation where none existed previously. Tip asymmetry may be overlooked preoperatively, or it may be caused by asymmetric excision of lateral crura, asymmetric placement of a columellar strut or placement of an overlong columellar strut, as well as other causes. Several surgical maneuvers are available to address the deviated nose35,36 and are addressed in this text (Murakami et al., Chapter 8).
Skin-Soft Tissue Envelope
In the unoperated nose, the skin-soft tissue envelope has well-defined tissue planes in which avascular dissection may be undertaken. Vascular supply and lymphatics are found superficial to the nasal musculature.37,38 Dissection in the proper tissue planes (areolar tissue plane, i.e., submusculoaponeurotic) preserves nasal blood supply and minimizes postoperative edema. Operating in the more superficial planes not only leads to a bloody surgical field but also risks damage to the vascular supply with potential damage to the skin. Once the skin-soft tissue envelope is damaged, it can never be fully restored. The damaged skin creates an aesthetically displeasing appearance.37,38
In revision rhinoplasty, the normal tissue planes are no longer present. Therefore, there is an increased risk, compared with primary rhinoplasty, of damage to the skin-soft tissue envelope. Meticulous dissection is therefore essential in this setting.