Primary rhinoplasty: An Indian perspective

ABSTRACT The spectrum of indications for rhinoplasty in Indian patients is very wide. An ill-defined nose with lack of projection and broad osteocartilagenous framework is the commonest problem. A large number of patients require narrowing of the framework by osteotomies, alar wedge resection,and augmentation by a suitable fill, preferably a cartilage graft. The technique of rhinoplasty in Indian patients with special emphasis on cartilage grafting has been discussed here. Cartilage grafts, when used as a fill, produce soft, natural results.


INTRODUCTION
hinoplasty is perhaps one of the most fascinating of all aesthetic procedures.Not only does it require orientation in three dimensions, but the surgeon also has to develop a so-called "feel" as the exposure is limited.Additionally it is an operation of judgment rather than technique and has a long learning curve.In this era of aesthetic surgery, proficiency in primary rhinoplasty becomes an essential requirement for modern day plastic surgeons.Literature is often divided as to the best technique, [1] but emphasis should be laid on the individuality of the case and familiarity with different manoeuvers.
In the current article, the spectrum of patients seeking rhinoplasty at our institute, the corrective operations, the technique of cartilage grafting and the results are discussed.

MATERIALS AND METHODS
In the last 15 years, 316 patients were operated for primary rhinoplasty at our institute.192  The indications were classified according to the primary deformity or the dominant feature: [Table 1].
1. Ill-defined nose: A nose that lacks projection, has broad osteocartilagenous frame work (OCF), has a broad lobule [Figure 1].This variety constituted nearly 40% of all our patients.Such noses are encountered very often in clinical practice, hence this category is generally referred to as a 'typical nose'.These noses classically require augmentation, narrowing of the pyramid by osteotomies, tip plasty and alar wedge resection (AWR).osteotomies and alar wedge resection may be required.Hence, these operations should be called 'rhinoplasty' rather than 'correction of cleft lip nose'.Most of the cases require an open technique. [2]Closed technique [3,4] can be used for mild deformities.
Planning: All the operations were planned by clinical examination, careful analysis of photographs and tracings of the profiles.For cases of augmentation and contour fill, a template of the defect was made.This was used as reference to shape the graft [Figure 2a, b].
The open approach seems attractive as it gives excellent exposure.Accurate closure of this incision is required.Improper closure is one of the causes of distortion of lobule.
B] Technique of different manoeuvers 1. Osteotomies [Figure 8]: Lateral and transverse osteotomies [2,10] were done by external / percutaneous technique with a 2 mm osteotome; medial osteotomy with a 5 mm straight osteotome with a guard   (described later) Ethmoid (perpendicular plate) osteotomy [2] was done by internal technique with a 5 mm osteotome without guard.2. Cartilage grafting: Most of the augmentations and contour fills were done by cartilage grafting.a) Stacked cartilage graft: [2,11] Conchal cartilage was harvested from one or both the ears and septal cartilage grafts as necessary [Figure 3a].It was straightened by cross hatching on the concave side and cut into strips [Figure 3b].These were stacked together with additional strips of septal cartilage as top layer. [1]The several layered graft was shaped to resemble the previously made template [Figure 3c].Grafts of various sizes and shapes can be fabricated as shown [Figure 3d].These were inserted in a generous pocket and maintained in position by pull out sutures of 6-0 nylon [12] [Figure 4].b) Costal cartilage / costochondral graft: 9th or 10th costal cartilage was harvested and straightened using Gibson's principle of balanced cross section [13] (Controlled scoring on the concave side of the curvature) [Figure 5a].Costal cartilage provides abundant volume and can be used where stacked conchal grafts would be inadequate.These are used mainly in cleft lip noses for augmentation of the dorsum and alar base and for the columellar strut.Costochondral graft is used for cantilever effect by fixing over bony dorsum [14] [Figure 5b]. 3. Tip plasty: Done by modified Lipsett technique. [2]The cartilages were delivered as bipedicled flaps.The excess cephalic portion was excised.The domal area of the remaining portion was weakened by scoring or cross hatching [Figure 7]. 4. Alar wedge resection (AWR): done by modified Weir technique [2,15] [Figure 9].
The technique of the most commonly performed operation -correction of ill defined or 'typical nose' is described in greater detail here.Tracings of the profile [Figure 2a]: Many patients are unaware how they look in profile.A patient's perception of his face is the familiar frontal view and that too as a mirror image.It is a good practice to make a tracing of the profile and superimpose it with a drawing of an imaginary ideal profile.This gives an idea of the areas where the nose requires a fill and the areas where the tissues are in excess.
Carving of templates [Figure 2b]: Templates can be carved out of a cake of soap.These can be used as a reference to shape a graft or implant.
Filling the defect with clay also gives a reasonable idea of the volume and shape of the fill.
The basic technique is generally described as stages or steps.It is better to call them components as the sequence of execution is not rigid.In fact the stage or component of hump reduction is not even required in eighty percent of the cases.
Western literature mentions the use of local anaesthesia for rhinoplasty.In reality, very few operations are possible The marking would include defining the midline, areas that need augmentation or reduction, the osteotomy lines, lines for AWR etc.
The conchal cartilage (costal when planned) is then first harvested and one surgeon contours and shapes it according to the needs [Figure 3c, d].The other surgeon proceeds with the nose.
For a typical nose, the best exposure would be to use both transfixion and infracartilagenous (rim) incisions and deliver the alar cartilages as bipedicled flaps.If AWR is planned, taking these incisions beforehand improves the overall exposure.
Degloving of the skin and soft tissue envelope (SSTE) should be done in a plane close to the osteocartilagenous frame work.An easy way is to expose the nearest cartilage (lateral for intercartilagenous, alar for rim) and follow the surface upwards.Extensive degloving is required in cases where the envelope needs to be draped on a significantly modified framework, as in major augmentation.
The cartilagenous septum is exposed by elevating the mucoperiochondrial flaps bilaterally.Raising these flaps in a correct bloodless plane is important.Near the caudal end, the cartilage is scratched with a knife till a pale white surface is exposed.This plane is followed to raise the flaps.The dorsal border of the septum is separated from the attachment of lateral cartilages by two parallel incisions on either side [Figure 6 a].The upper ends of these incisions will lead the surgeon to the beginning points of the medial osteotomies [Figure 6 b].The septal graft is harvested next, keeping the dorsal and caudal borders (the L-strut) intact and handed over to the first surgeon, who would then add the septal strips to the conchal strips to prepare graft/s of desired shape [Figure 3c, d and 4].
Tip plasty is performed by delivery of the alar cartilages, excision of the excessive cephalic portion ('the cephalic trim'), excision of excessive interdomal tissue and scoring or weakening the domes [Figure 7].The transmucosal interdomal suture is taken later, at the time of closure [Figure 7].
The lateral osteotomies [Figure 8 a,b] should preferably be low to low and should stop at the level of the medial canthi superiorly.The nose should not be narrowed above this level as it breaks the diverging curved aesthetic lines.Lateral osteotomy is possible through a single stab incision and maneuvering the 2 mm osteotome above and below, along the previously marked line.A transverse component should then be added, through another horizontal stab incision at the canthal level.The transverse osteotomy breaks the bones in a controlled manner compared to a manual greenstick out-fracture.The medial osteotomies [Figure 8 c,d], done with a 5 mm osteotome with guard, should separate the nasal bones from the perpendicular plate of the ethmoid.The nasal walls are then shifted medially with gentle compression applied over a wet gauze [Figure 8 e].The ethmoid osteotomy is not indicated in a typical nose.However, when required to correct the high bony deviation, it is done by a 5mm osteotome placed between the perpendicular plate and the mucoperiosteal flap on the side of deviation [Figure 8 f].
In cases of hump removal, the osteotomies are designed to close the open roof, i.e. to bring the upper portion of nasal walls towards the midline.In a typical nose, the purpose of these osteotomies is to shift the lower portion of the nasal walls medially so as to narrow the base of the pyramid [Figure 8 g].
The stacked graft is inserted at the desired place.The two threads at either ends are brought out as pull out sutures, using a straight needle and the ends are kept long [Figure 4].
The Alar Wedge Resection is done by modified Weir technique.Excision is designed so as to narrow the nostril sill.A small triangular flap breaking the straight incision lines preserves the natural contour of the nostrils [Figure 9].The transmucosal interdomal suture is now taken [Figure 7], followed by closure of incisions.The pull out sutures are tied last, over a bolster of tulle gras (to be removed at day 5).The shape of the nose is maintained with porous adhesive tape.Plaster of Paris splint is kept for three weeks to maintain the nasal walls at the new medial position.

RESULTS
Enumerated below are the details regarding the exposure and various manoeuvres performed [Table 2].

Bhat and Patel
Indian J Plast Surg Supplement 2008 Vol 41 Most of the operations were possible by the closed approach.Open approach was required mainly for primary tip deformities and cleft lip noses.The most frequently performed manoeuvers were cartilage grafting, osteotomies and alar wedge resection.
Type of fill used is described in Table 3.
38 patients received grafts at more than one site.
Overall results were classified according to patient satisfaction, satisfaction of the surgeon and assessment by a neutral observer (usually an ENT / Surgical colleague) [Table 4].
Most excellent and good results were seen in cases of ill-defined nose, augmentation and deviated nose (Representative patients 1,2,4) .Stacked cartilage grafts performed very well.They produced a soft, natural result.Warping, lack of volume and resorption were not a problem.The largest stacked graft was a 10 layered graft of conchal (bilateral) and septal cartilages; measuring 10 mm in thickness and 25 mm in length.The Turkish delight technique did not work well in the authors' hands. [16]erage results mostly belonged to the categories of cleft lip nose and small nose.Poor results were due to two instances of complete resorption and two instances of partial resorption of iliac bone graft, infection and partial resorption of cartilage graft in one case, and failure to achieve good symmetry in three cases of cleft lip nose.
Almost all cases of deviated nose required septal correction and osteotomies.Correction by camouflage alone was possible only in three cases having no significant septal deviation.

DISCUSSION
An ill-defined nose is the most commonly encountered problem in clinical practice.These noses typically have a broad OCF, broad lobule and tip and also lack projection.
It is easy to think that the broadness is apparent, because of lack of projection.In fact in most cases it is real, and these noses need to be narrowed by osteotomies and AWR.Initially the authors used to follow the closed or intranasal technique for lateral osteotomy, but have now shifted to external percutaneous technique, which gives better control and is easier to perform.It is also better to add a transverse osteotomy at the level of medial canthi, rather than performing a greenstick outfracture.
The classical reduction rhinoplasty described in western literature [1] may not be fully applied in the Indian context.The typical Indian nose lacks projection and hence requires augmentation more often than reduction.Some noses may even need reduction at one place and augmentation at the other.Hence cartilage grafting is an integral part of Indian rhinoplasty and today's surgeon must be well versed with the technique and use of cartilage grafts.
Stacked cartilage grafts produce soft and natural results. [11]Problems of infection, resorption and warping are almost non-existent.Wrapping these grafts in fascia [2] is not required in Indian patients, as the sharp edges do not show through the thicker skin.In fact, the edges give better definition.Curved conchal cartilage can be straightened by scoring on the concave side.Usually one concha provides enough volume for a graft of 4 to 5 mm in thickness.With both conchae and additional strips of septal cartilage, a large graft, almost a centimetre thick, can be sculpted.Costal cartilage provides the abundant volume required in cleft lip noses.Warping of the costal cartilage can be avoided by preserving the perichondrium and breaking it only along the curvature (the concave side). [13]The only instance of warping in our patient was due to unfamiliarity with technique of scoring and lack of understanding of the Gibson's principle. [13]Although done in only two cases, the Turkish delight technique [16] was a failure at the authors' hands as the grafts could not be properly shaped.Postoperative moulding was not possible because of pain.The authors have no experience of calvarial grafts, but the iliac grafts were disappointing.

CONCLUSION
In Indian context most of the patients seek correction of obvious deformities.The typical deformity is a broad, nonprojecting nose.Cartilage grafting, osteotomies and AWR are important and most frequently performed manoeuvres.In equivocal situations it is prudent to err on the side of putting into practice the important tenets of rhinoplasty -osteotomies, cartilage grafting and alar wedge resection.Good results can be obtained by familiarity with these three techniques.

Figure 2a :Figure 1 :Figure 2b :Figure 3a :
Figure 2a:The superimposition of actual and an imaginary ideal proÞ le ( based on the surgeon's judgment and patient's expectations ).The areas that require either augmentation or reduction can thus be identiÞ ed

Figure 6b :
Figure 6b: The proximal end of this incision is the beginning point of medial osteotomy Figure 6a: An incision to separate the lateral cartilages from the septum

Figure 5b :
Figure 5b: Two examples of costocondral graft.The proximal bony part can be used for screw Þ xation

Figure 5a :
Figure 5a: Straightening of costal cartilage by scoring incisions on the concavities.It is better to wait for half an hour before insertion, as most of the warping takes place by that time

Figure 4 :
Figure 4: Two threads of 6-0 nylon at either end, brought out as pull out sutures using a straight needle, hold the graft in place

Figure 9 :
Figure 9: Alar wedge resection.A small triangular ß ap at the sill preserves the natural contour of the nostril

Figure 8f :
Figure 8f: The ethmoid osteotomy Figure 8g: A -The osteotomies serve to close the 'open roof' in cases of hump reduction, by shifting the upper portion of the nasal walls medially.B -The purpose of osteotomies in a typical nose is to bring the lower portion of the nasal walls medially, so as to narrow the framework

Figure 10 :Figure 11 :Figure 13 :
Figure 10: (Patient 1) Typical or ill-deÞ ned nose.Osteotomies and a seven layered cartilage graft have produced the two dorsum deÞ ning lines in the frontal view.Augmentation of the proÞ le is signiÞ cant and tip has better deÞ nition

Figure 12 :
Figure 12: (patient 3) Previous submucous resection has resulted in a supratip depression.A simple onlay graft to the dorsum may sink because of lack of structural support.The deformity is corrected by a cantilevered costochondral graft

Figure 22 :Patient 10 [
Figure 22: (patient 13) Deviated nose corrected by camouß age alone.This was possible because the septum was not deviated

Table 1 : Indications with their numbers
RIndian J Plast Surg Supplement 2008 Vol 41 Small or foreshortened nose: Corrected by cartilage graft / bone graft.7. Long nose (drooping tip): Corrected by cephalic trim, excision of caudal septum.8. Tip deformities: Inadequate projection, boxy tip etc. 9. Cleft lip nose: Mere correction of cleft deformity alone may not be enough to obtain a satisfactory aesthetic result.Additional procedures like augmentation, 2. Lack of projection of osteocartilagenous framework (OCF): The OCF is not broad; hence the nose does not require osteotomies.Augmentation may be done by cartilage graft / bone graft/ implant.AWR / tip plasty only if required.3. Contour deformities: The nose has adequate overall projection.Contour defects include lateral depressions, dorsal deformities (post traumatic or post SMR supratip depressions, nasofrontal depressions).These are corrected by cartilage grafts.4. Deviated nose: Generally there is deviation of the septum.The septum has to be corrected by septoplasty.High deviations involving the bone may require ethmoid osteotomy [Figure 8 f].Lateral and medial osteotomies are required for correction of the lateral walls.Residual deformity, if any, is camouflaged by cartilage grafts.Very few mild deformities (without septal deviation) can be corrected by camouflage alone.5. Dorsal hump (those associated with deviated nose are included in deviated nose): Dealt with by hump removal and osteotomies.6.