Keywords rhinoplasty - osteotomy - photography
Introduction
As a surgical method used in rhinoplasty, lateral osteotomies have been described
and performed according to the surgeon's preferences and training. The main objectives
of osteotomies are to narrow the nose, close open roof deformities secondary to deformities
originating after nasal hump removal, and to correct nasal asymmetries on the bony
pyramid. There is no ideal technique for osteotomies in rhinoplasty, allowing each
surgeon to perform it in a different way.
In this study, we aimed to compare the efficiency of lateral osteotomies performed
by one surgeon at our hospital in Curitiba, using different techniques to achieve
the same objective as a surgical result. Therefore, we evaluated comparisons between
the pre- and post-operative pictures of 74 patients from both genders who were divided
in to 2 groups of 37 patients each. Patients from the first group underwent rhinoplasty
with lateral osteotomy, while patients from the second group underwent rhinoplasty
with microperforating osteotomy, both in the period between January 2010 and October
2011. After the study, the results were discussed using statistical analysis of the
photographic measurements.
Literature review
Rhinoplasty techniques have been described for centuries. Initially, according to
Egyptian papyri[1 ], rhinoplasty aimed to reconstruct nasal soft tissues to correct acquired nasal deformities
such as, for example, that of mutilated people. In 1823, the German surgeon Dieffenbach
[2 ] was the first to perform alterations on the osteocartilaginous nasal dorsum by external
incisions. In around 1887, Roe
[3 ] was the first surgeon to describe purely cosmetic nasal surgery. In the 19th century, Joseph
[4 ] described the first surgical technique to access nasal deformities of the nasal
bones.
Lateral osteotomies are rhinoplasty surgical maneuvers that enable the surgeon to
narrow the nose, close open roof deformities resulting from hump removal, and correct
asymmetry of the nasal bones. They can be performed by continuous technique, creating
a single fracture along the lateral portion of the nasal process of the maxilla and
nasal bones, or by perforating osteotomy, which creates a series of postage stamp–type
perforations along the same line, along the lateral portion of the nasal process of
the maxilla and nasal bones. Webster et al .[5 ] described the “high-low-high” surgical maneuver sequence to lateral osteotomies
aimed at preserving the insertion of the head of the inferior turbinate in the pyramid
aperture.
Several lateral osteotomy techniques have been described, but with no consensus about
which would be the most effective. The selection of a technique depends on the preferences
and individual results of each surgeon. An osteotomy is expected to produce a reliable
effect and be reproducible, with minimum trauma to nasal soft tissues, achieving a
complete fracture with minimal sequel.
Several studies have compared continuous osteotomies to microperforating osteotomies
in terms of edema, post-operative ecchymosis, and osteotome size. These studies verified
that there was less edema and ecchymosis in microperforating osteotomies, especially
when a smaller, straight osteotome, without guide, of 2 or 3 mm was used[6 ]
[7 ]
[8 ]
[9 ]
[10 ]
[11 ]. Tardy and Denneny
[6 ] demonstrated that, when performed with 2-mm osteotomes, lateral microperforating
osteotomies cause less ecchymosis and soft tissue trauma compared to continuous osteotomies.
Gryskierwicz and Gryskiewicz
[7 ] concluded that microperforation osteotomies using 2-mm osteotomes resulted in less
edema and post-operative ecchymosis compared to continuous osteotomies using 4-mm
guided osteotomes. Rohrich et al .[8 ] demonstrated that microperforating osteotomies cause less nasal mucosal damage than
continuous osteotomies.
Few studies have demonstrated the effects of lateral osteotomies in rhinoplasty comparing
microperforating and continuous techniques. In 2010, Zoumalan et al .[12 ], through photographic analysis of 60 patients who had undergone rhinoplasty, concluded
that both techniques created a statistically significant narrowing of the base of
the nose but that there was no statistical difference between both techniques. However,
none of the techniques resulted in a statistically significant narrowing of the nasal
dorsum. In Kortbus et al .[12 ], photographic study of 20 patients led to the conclusion that lateral osteotomies
result in a statistically significant reduction of the base of the nose that does
not occur at the dorsum. In that study, a comparison to a group that underwent microperforating
osteotomy was not established. Therefore, due to a lack of information in the literature,
we decided to compare the techniques applied in our practice to establish the efficacy
of these surgical approaches in rhinoplasty.
Method
The present study was carried out at our hospital (Curitiba Paraná, Brazil), and comprised
74 randomly selected patients from both genders who underwent rhinoplasty with lateral
osteotomy to narrow the bone pyramid of the nose. Of these, 37 patients underwent
continuous osteotomies, and the other 37 underwent microperforating osteotomies. The
same surgeon operated on all patients. The local ethics committee approved the study
under approval number 12/2010. All the procedures were performed using local anesthesia
and sedation using the basic closed techniques, where all osteotomies were performed
via the endonasal route[13 ]. Continuous osteotomies were carried out using a guided 3- or 4-mm curved osteotome,
preceded by periosteum displacement, creating a single fracture along the lateral
portion of the nasal process of the maxilla and nasal bones. Microperforation fractures
were created with a 2- or 3-mm osteotome without guide and without periosteum displacement
by making several perforations on the same line orientation, along the lateral portion
of the nasal process of the maxilla and nasal bones ([Figure 1 ]). All the lateral osteotomies followed the “high-low-high” sequence: beginning at
the piriform aperture, above the head of the inferior turbinate (high), extending
downwards along the maxilla upward process (low), and ending by ascending 2 mm before
the inner canthus of the eye (high). At the end of the osteotomies, the fractures
were completed with a digital compression maneuver. By the end of each rhinoplasty,
a dressing was applied on the nasal dorsum using micropore tape and a thermoplastic
splint molded over the dorsum of the nose. Nasal packing was not utilized in any of
the performed nasal surgeries.
Figure 1. (a) Continuous line indicates continuous osteotomy. (b) Outline depicts microperforating
osteotomy.
Frontal photographs of all the patients were captured (from a 5-foot distance away
from the patients) in the pre- and post-operative periods, using the same camera,
for aesthetic comparison of the surgical procedures. The post-operative photos were
obtained 180 days after the surgery to avoid the effect of post-operative edema. In
both cases, the comparison was performed by measuring the nasal dorsum width at its
wider portion and the nasal bony base at the wider portion of the ascendant maxilla
process using photographic analysis of pre- and post-operative images.
To obtain measurements and a possible comparison, the measurement of the wider portion
of the nasal dorsum for both the pre- and post-operative images was divided into a
fixed parameter in each patient photograph and labeled as the interpupillary distance,
minimizing possible errors of distance on the photographs and establishing comparison
by means of one ratio measure. The same process was carried out by measuring the bony
nasal base at its wider portion of the ascendant process of the maxilla and subsequently
dividing it by the interpupillary distance. One researcher made the measurements mentioned
above utilizing Adobe Photoshop 5 CS ([Figure 2 ]).
Figure 2. Image A: Pre-operative photograph (left). Image B: Post-operative photograph (right).
In both pictures, the top line is the interpupillary line (fixed pre- and post-operative
parameter); the inferior line is the nasal base measurement, and the medium line represents
the nasal dorsum measurement (variable parameters to be analyzed).
The results of the cited ratios, in terms of the variables of the dorsum and base
of the nose, were compared considering the pre- and post-operative periods for both
groups of patients. The 2 techniques were compared retrospectively by considering
the obtained results.
Results
Based on the nature of the analyzed data, we proceeded with the statistical approach
deemed appropriate. Student's t -test was used for statistical analysis of the following measurements:
The relative values of the dorsum and base of the nose before and after the continuous
and microperforation techniques, and the differences of the nasal dorsum and base
between the continuous and microperforation techniques. The statistical level adopted
was p < 0.05.
Regarding the 37 patients who underwent continuous osteotomies, we obtained statistically
significant differences for the pre- and post-operative ratios between the nasal dorsum
and interpupillary distance ([Table 1 ]), as was also observed for the ratios between the base of the nose and interpupillary
distance ([Table 2 ]).
Table 1.
Statistical analysis of the pre- and post-operative measurements of the nasal dorsum
with continuous technique.
Operative stages
N
Relative Value of Nasal Dorsum
p
min–max
average
± sd
Pre
37
0.1663–0.2814
0.2383
± 0.0297
0.0000
Post
37
0.1360–0.2698
0.2079
± 0.0279
Note: N, Number of patients; min–max, minimum and maximum values; sd, standard deviation;
p, statistical significance level. Source: The author (2011).
Table 2.
Statistical analysis of the pre- and post-operative measurements of the base of the
nose with continuous technique.
Operative stages
N
Relative Value of Base of the Nose
p
min–max
average
± sd
Pre
37
0.2462–0.4597
0.3686
± 0.0406
0.0000
Post
37
0.2366–0.3936
0.3222
± 0.0341
Note: N, Number of patients; min–max, minimum and maximum values; sd, standard deviation;
p, statistical significance level. Source: The author (2011).
Evaluating the 37 patients who underwent rhinoplasty with lateral perforating osteotomies,
the pre- and post-operative ratios between the nasal dorsum distance and interpupillary
distance were statistically significant ([Table 3 ]), as was the ratio between the distance of the base of the nose and interpupillary
distance ([Table 4 ]).
Table 3.
Statistical analysis of the pre- and post-operative measurements of the nasal dorsum
with perforation technique.
Operative stages
N
Relative Value of Nasal Dorsum
p
min–max
average
± sd
Pre
37
0.1522–0.3005
0.2271
± 0.0392
0.002
Post
37
0.1286–0.2739
0.1990
± 0.0345
Note: N, Number of patients; min–max, minimum and maximum values; sd, standard deviation;
p, statistical significance level. Source: The author (2011).
Table 4.
Statistical analysis of the pre- and post-operative measurements of the base of the
nose with perforation technique.
Operative stages
N
Relative Value of Base of the Nose
p
min–max
average
± sd
Pre
37
0.30–0.5028
0.3824
± 0.0550
0.0000
Post
37
0.2697–0.4262
0.3354
± 0.0413
Note: N, Number of patients; min–max, minimum and maximum values; sd, standard deviation;
p, statistical significance level. Source: The author (2011).
There were no statistical differences when both osteotomy techniques were compared
([Table 5 ]).
Table 5.
Statistical analysis of the average difference of the nasal dorsum and the base of
the nose between continuous and perforation techniques.
Techniques
n
Difference of the Dorsum
p
min–max
average
± sd
Continuous
37
−0.006 to 0.0711
0.0305
± 0.0199
0.63
Microperforation
37
−0.0217 to 0.0754
0.0281
± 0.0223
Techniques
n
Difference of the Base
p
min–max
average
± sd
Continuous
37
−0.0068 to 0.1369
0.0465
± 0.0259
0.94
Microperforation
37
−0.0007 to 0.1408
0.0470
± 0.0313
Note: n, Number of patients; min–max, minimum and maximum values; sd, standard deviation;
p, statistical significance level. Source: The author (2011).
Discussion
In rhinoplasty, several maneuvers, techniques, sutures, and grafts are combined in
the same surgery to obtain the best aesthetic and functional result for the patient.
The lateral osteotomy is a rhinoplasty surgical technique whose main objective is
to narrow the nose and create a harmonious aesthetic effect. There has been discussion
regarding the best lateral osteotomy technique, whether the periosteum should be displaced,
the stability of the fracture, post-operatory edema, and ecchymosis and tissue damage
of the nasal mucosa. It is not possible to reach a consensus regarding what the best
option would be; it all depends on surgeon preference and experience. However, some
studies in the literature have reported that osteotomies without periosteum displacement
have resulted in less post-operative edema and ecchymosis than when the periosteum
is displaced, creating less post-operative morbidity because the periosteum and its
vascularization remain attached to the bone, providing better nurturing to the healing
area.
The majority of the surgeons at our hospital perform rhinoplasty. All of them follow
the same surgical precept and surgical steps, from anesthesia to the final nasal dressing,
but as expected, each has his own preferences and different appropriations of the
technique, which is what propelled us to the development of this work.
Some years ago, in our practice, rhinoplasties were predominant in Caucasian patients;
therefore, few alterations in the width of the nasal base were required. However,
this profile has changed in recent years; we have observed the miscegenation of our
patients and thus observed an ethnic alteration of the noses that required effective
osteotomies to obtain nasal narrowing.
The main differences between osteotomies have to do with the post-operative period,
when greater edema and ecchymosis are observed following continuous osteotomy in comparison
to perforating osteotomy, a fact that can generate more discomfort for the patient
and a longer convalescence period. Concerning technique choice, it is the surgeon's
duty to decide which to use, since, as we have verified, both techniques are efficient.
The surgeon must be comfortable with the elected technique, and be secure with the
utilized osteotomes to obtain better results.
Conclusion
The present study verified that there are no statistically significant differences
between the results of microperforating and continuous lateral osteotomies, with both
being effective at narrowing the nasal dorsum and base. Therefore, we conclude that
both techniques deliver a statistically significant narrowing of the nasal dorsum
(p < 0.05). This is contrary to the data available in the researched literature, in
which only the narrowing of the base through both techniques is statistically significant,
without mention of the nasal dorsum.
