Rhinoplasty

A “Polly Beak” deformity usually results from prior rhinoplasty surgery, specifically surgery directed at removing a large dorsal hump. A dorsal hump consists of excess bone and cartilage along the nasal dorsum. A pollybeak deformity occurs when a dorsal hump is not fully removed in the supratip area. The supratip region corresponds to the area just above the tip of the nose along the nasal dorsum. Excess cartilage along the dorsum not removed in prior rhinoplasty results in fullness in the supratip area causing this region of the nose to appear overly convex in shape without a break between the tip and nasal bridge. This lack of a supratip break results in the nose resembling the beak of a parrot on profile view. Other causes of supratip fullness, and subsequent “Pollybeak Deformity” are excess scar tissue formation at the supratip, overresection of the nasal bones, as well as a loss of tip support?

If the deformity is caused by excess cartilage remaining in the supratip area, revision rhinoplasty is necessary to surgically remove the excess cartilage. If scar tissue is causing the fullness, serial steroid injections can be attempted, along with taping of the nose to apply compression at the supratip. If conservative therapy fails surgical correction with revision rhinoplasty will be necessary to remove the excess scar tissue. If over resection of the nasal bones causes excessive lowering of the dorsal height above the supratip area, augmentation grafting is necessary to build up the dorsum. This is routinely done in my practice with diced cartilage and fascia grafts (DCF). Lastly, the loss of tip support can be treated with cartilage grafts. A columellar strut graft is typically used to reestablish the appropriate tip support and projection.

The “Pig Nose” Deformity commonly refers to an overly short or upturned nose. This is a complication from prior rhinoplasty surgery, where the tip was overly rotated in the upward direction. This is typically a result of excessive removal of cartilage particularly at the caudal septum, which is at the bottom portion of the nose between the nostrils. Excessive scar tissue formation after rhinoplasty can also results in tip retraction.

The main goal in correcting this type of deformity is to lengthen the nose and “turn down” the tip. This is typically accomplished with revision rhinoplasty utilizing both septal extension grafts and extended spreader grafts. Septal extension grafts are inserted at the end of the short septum to increase the length of the septum and overall length of the nose. Septal extension grafts typically require a very rigid piece of cartilage to be effective. Costal cartilage, otherwise known as rib cartilage, is commonly used for this maneuver. Extended spreader grafts are also used to further lengthen the nose and provide support.

The inverted-V deformity is a complication which can sometimes arise after rhinoplasty surgery. When looking at the patient from a frontal view an upside down V-shaped shadow is cast along the middle third of the nose. This unfavorable cosmetic complication usually results from separation of the upper lateral cartilage attachments from the dorsal septum and the caudal margin of the nasal bones, resulting in collapse of the middle nasal vault. This complication can arise if an inexperienced surgeon removes a large hump along the nasal dorsum, and does not support the upper lateral cartilage to prevent collapse of these structures. Collapse of the upper lateral cartilage can also result in functional complication involving nasal breathing. Breathing is obstructed because of narrowing of the internal nasal valve, the narrowest section of the nasal airway. The internal nasal valve represents the airway space between the upper lateral cartilage and the septum. Being the narrowest segment of the airway, small changes in the support structures of the airway can lead to noticeable breathing difficulty. A revision rhinoplasty is needed to correct the cosmetic and functional complications of this condition.

All of the above complications result from collapse of the upper lateral cartilage due mostly likely to unidentified separation of the cartilage attachments from the nasal septum and nasal bones during prior rhinoplasty surgery. Commonly, revision rhinoplasty is needed to correct these problems. The use of spreader grafts is typically needed to help support the cartilage and open the internal nasal valve. Spreader grafts are small rectangular shaped cartilage grafts made from cartilage taken from nasal septum, ear, or rib if need be. They are placed between the nasal septum and upper lateral cartilage, and help to increase the width of the internal valve. They are they sutured to the septum and upper lateral cartilage, supporting the upper lateral cartilage, and preventing further collapse.

A saddle nose deformity is characterized by a collapse of the nasal dorsum with decreased dorsal height. They are seen after rhinoplasty surgery when there is over aggressive cartilage removal with dorsal hump reduction. Over resection of the cartilaginous septum leading to inadequate L-strut support can also result in this deformity. Minor saddle nose deformities that do not result in structural weakness of the nose can be corrected with dorsal grafts. My particular graft of choice is the diced cartilage fascia graft (DCF). For moderate to severe saddle nose deformities with structural compromise, extensive cartilage grafting is needed to rebuild the nasal framework. This typically involves use of costal cartilage (rib cartilage) due to its increased strength. DCF grafts would also be used for cosmetic enhancement once the nasal framework is rebuilt.

An overly pinched tip after rhinoplasty is typically a result of over resection of the lateral crura. This can also lead to nasal obstruction with collapse of the nostrils on inspiration due to structural weakness at the external nasal valve. An experienced rhinoplasty surgeon will typically maintain at least a 6-8mm thick strip of lateral crura to ensure appropriate support for cosmetic and functional purposes. Cartilage grafts are usually required to enhance the strength of the lateral crura. Alar batten grafts, as well as lateral crural strut grafts, are typically used to treat this deformity. Lateral crural malposition can also lead to an overly “Pinched” Tip. This occurs when the caudal (lower) border of the lateral crura is positioned significantly inferior to the cephalic (upper) boarder. Lateral crural repositioning with lateral crural strut grafts can correct his complication.

The nasal bones align like a peaked roof on a house. The peak of the roof is represented by the top of the nasal bridge. At this peak, the nasal bones meet to form the nasal bridge. The sides of the roof gently slope off the peak as do the nasal bones extend from the nasal bridge to the face. When a large hump is removed from the top of the nasal bridge, the “peak” of the roof is removed. This leaves a space between the nasal bones, resulting in a flat or concave deformity along the bridge, the “open roof” deformity. In order to reposition the nasal bones, placing them back together to recreate the “peak” of the roof, osteotomies are used. Once the nasal bones are freely mobile after osteotomies, they are be realigned, closing the “open roof” deformity.

Alar retraction refers to significant upward ascent of the alar rim leading to alar columellar disproportion. This can be caused by over aggressive resection of the lateral crura during cephalic trimming. It can also result from lateral crural malposition. Minor cases of alar retraction can be treated with alar rim grafts which help to move the alar rim in a lower position. Lateral crural strut grafts can be used to correct lateral crural malposition. In more severe cases of alar retraction composite grafts consisting of conchal cartilage and skin may be needed to reposition the alar rim, as well as provide lining inside the nose.