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Ancillary Rhinoplasty Maneuvers Fayetteville

Ancillary rhinoplasty procedures are required much less frequently than the primary rhinoplasty maneuvers described in the previous section. These anatomic problems that these maneuvers correct are seen much less frequently than nasal dorsum or nasal tip problems. These less commonly seen concerns can result from trauma, developmental abnormalities, or a previous rhinoplasty. The correction for these problems can be done at the same time as the primary rhinoplasty procedures reviewed in the previous section.

The retracted columella is sometimes seen in a patient seeking a rhinoplasty, but rarely is it the primary concern. The normal anatomy in this area is the columella being slightly lower than the adjacent alar wings. When this situation is reversed, the situation is referred to as a “retracted columella”. As with all areas of the nose, the nasal skeleton supports the nasal skin. In this circumstance, the medial alar cartilage and the septal cartilage do not provide enough projection of the columella to allow the normal anatomical relationship previously described. A cartilage graft needed to correct the problem, and in extreme cases, a bone graft may be needed. In most situations, a cartilage graft will suffice for the correction, and it is easily harvested from the nasal septum which is in the same surgical field. The cartilage graft is carved to the appropriate size and shape, and is then secured with very small sutures. After the graft is placed, the columella will appear lower and more in relation to the alar wings as previously described. The cartilage graft is shown in the diagrammatic image below and is dark blue.

Columella graft, side view

The inferior (bottom) of the alar wings are either positioned too high or are underdeveloped in some patients. In this circumstance, the height between the columella and the alar wings in more than normal, and the sides of the nose appear too high. The deficiency in this circumstance is cartilage and skin. Because like tissues are preferably used to correct this problem, both skin and cartilage are chosen as the graft. This type of graft is referred to as a composite graft. A composite graft is defined as a graft that is made up of two or more tissue types. The composite graft in this circumstance is very small, and can be easily harvested from the ear. Because the graft is very small, the blood supply can re-establish quickly. The composite graft is placed inside the nose at the caudal (bottom) border of the lateral alar cartilage after the alar rim is “expanded”. The graft is secured with very small sutures. The composite graft acts as a “shim” which will hold the rim of the alar wing down. The alar graft is shown below in the diagrammatic image and is represented in tan.

Alar graft, caudal view

Wrinkled alar wings (area beside the nasal tip) are not commonly seen in patients presenting for rhinoplasty. The alar wing wrinkling can result from trauma, developmental abnormalities, or a previous rhinoplasty. There are several techniques described for correcting the wrinkled alar wing, and the technique chosen depends upon the severity of the problem. In some circumstances, a simple repair of the natural cartilage is sufficient to correct the problem. In more severe cases, a cartilage graft is used, and it is secured over the natural alar cartilage with very small sutures. This cartilage grafting technique can also be used when there is inadequate alar support which results in external nasal valve collapse. When the external nasal valve collapses this results in airway obstruction during inspiration. Due to the complexity of this procedure, the open rhinoplasty technique is indicated. The lateral alar graft is shown below in the diagrammatic image and is represented in dark blue.

Alar graft, side view

Alar graft, front view

The under contoured glabella is another less common reason patients seek rhinoplasty. This is area at the top of the nose between the eyes. The under contoured glabella is not uncommon in patients that have incurred craniomaxillofacial trauma, and specifically naso-ethmoid trauma. When this occurs, the bone fragments can be comminuted (in many small pieces) which makes the primary repair very difficult. When this occurs, and the glabella is under contoured, a graft is sometimes used to recreate the normal contour at the time of the initial repair or at a later time. The graft in this circumstance is usually cranial bone, which is harvested from the side of the skull. Following the “replace like with like” principle, a bone graft would be the primary consideration in this circumstance. The diagrammatic image below shows the glabellar graft, which is represented in dark blue.

Glabella graft, side view

Glabella graft, front view

The “pinched nose” perfectly describes the appearance of a patient with loss of support in the middle portion of the nose (the area between the glabella and the nasal tip). A common cause of the pinched nose appearance is a previous rhinoplasty, and specifically an over reduction or displacement of the upper lateral cartilages. In addition to an aesthetic problem, this group of patients may also have a collapse of the internal nasal valve resulting in upper airway obstruction. The pinched nose requires multiple cartilage grafts to repair including a “spreader graft” (see section on spreader grafts in the surgical maneuvers section) and a graft to repair the damaged upper lateral cartilage. The goal in this group of patients is to correct the aesthetic problem and the functional problem. The pinched nose is typically repaired with a septal cartilage graft. Due to the complexity of this pinched nose repair, the open rhinoplasty technique is indicated. The diagrammatic images below show spreader grafts and upper lateral cartilage grafts in red and dark blue respectively.

The pinched tip front view

The pinched tip, side view