Sao Paulo Med. J. vol.113 número1

I

J o r g e I s h id a , J o s e p h L e e , E d s o n S h ir o m a , L u is C a r lo s I s h id a

S e c o n d a ry rh in o p la s ty : re c o n s titu tio n o f th e a lla r c a rtilla g e s

b y a rh in o p la s ty w ith a n e x te rn a l in c is io n

Otorhinolaryngology

Discipline, Hospital das Clinicas, Faculdade

de Medicina da

Universidade de Silo Paulo - Silo Paulo, Brazil

Presentation of 62 cases of secondary nasal deform ities treated by external incision. Several types of endonasal deform ities were observed, properly classified and 'repaired. W hen excessive ressection was observed, local

cartillage graft, septonasal or conchal types were em ployed.

UNITERM S: Nose. Secondary rhinoplasty.

INTRO DUCTIO N

C

l a s s i cs y m m e t r i ce n d o n a s a lr e s s e c t i o nr h i n o p l a s t yo f t h e a l l a r c a r t i l l a g e s .d o e s n o t e n a b l eD u ea t o t h i s , p r e s e n c e o f s e c o n d a r y e n d o n a s a l

d e f o r m i t i e s i s v e r y f r e q u e n t .

O p e n i n g u t i l i z a t i o n , w i t h a w h o l e e x p o s i t i o n o f t h e

c a r t i l l a g e s , e n a b l e d a n e x a c t e v a l u a t i o n o f d e f o r m i t i e s a n d ,

a s a r e s u l t , a m o r e p r e c i s e r e s t o r a t i o n .

I n a l l o f t h e c a s e s , w r o n g r e m o v a l s w e r e o b s e r v e d ,

r e s u l t i n g i n t h e m o s t d i f f e r e n t t y p e s o f d e f o r m i t y , r a n g i n g

f r o m s i n c e a s m a l l a s y m m e t r i a u n t i l a c o m p l e t e c o l l a p s e ,

w i t h t o t a l r e s s e c t i o n o f t h e c a r t i l l a g e s .

A f t e r R e t h i ( 4 ) , S e r c e r ( 5 ) , P a d o v a n ( 3 ) a n d , m o s t

r e c e n t l y , G o o d m a n ( 1 a n d 2 ) , S h e e n ( 6 ) , d i v u l g a t e d

r h i n o p l a s t y t h r o u g h n o s e o p e n i n g s , w e h a v e o b s e r v e d t h a t

t r e a t m e n t o f t h e s e c o n d a r y d e f o r m i t i e s a s w e l l a s s o m e

A d d r e s s f o r c o r r e s p o n d e n c e : J o r g e I s h id a

, R u a P a d r e P e r e ir a d e A n d r a d e , 5 4 5 I I h a d o S u I - E d . I I h a B e la , 1 2 3 / 1 2 4 S a o P a u lo - S P - B r a s il - C E P 0 5 4 8 0 - 0 0 0

c o n g e n i t a l o n e s , h a v e b e e n e x t r e m e l y i m p r o v e d b y t h i s

p r o c e d u r e . I n c i s i o n i n i t i a l l y u s e d w a s t h e o n e d e s c r i b e d

b y R e t h i ( 4 ) a n d , a f t e r w a r d s , w e h a v e a d o p t e d t h e o n e

p r o p o s e d b y G o o d m a n ( 1 a n d 2 ) , b e a r i n g t h e m e d i u m

p o r t i o n o f t h e c o l u m e l l a a n d i n a b r o k e n l i n e . T h i s

p r o c e d u r e r e s u l t e d , i n m o s t o f t h e c a s e s , i n a q u i t e i n v i s i b l e

s c a r 3 m o n t h s a g o .

I n s p i t e o f r e q u i r i n g a l o n g e r s u r g e r y t i m e , t h e w i d e

e x p o s i t i o n o f t h e a n a t o m i c e l e m e n t s , a m o r e s y m m e t r i c a l

r e p a r a t i o n o f t h e e l e m e n t s i s p o s s i b l e .

SURG ICAL TECHNIQ UE

I n c i s i o n b e g i n s i n t h e m a r g i n a l p o r t i o n o f b o t h o f

t h e w i n g s a n d i s e x t e n d e d t i l l t h e c o l u m e l l a .

E n d o n a s a l c u t a n e o u s d e t t a c h m e n t s t a r t s o n t h e p o i n t

s u b c u t a n e o u s c e l l u l a r t i s s u e i s m o r e f l a b b y c o n 'n u i n g '

s l o w l y i n d i r e c t i o n t o t h e c o l u m e l l a , w h e r e t h e r e i s a h i g h e r

a d h e r e n c e o f t h e s k i n t o t h e c a r t i l l a g e . I n t h i s p o i n t o f

s u r g e r y , i n c i s i o n s j o i n e a c h o t h e r a t t h e m e d i u m p a r t o f

t h e c o l u m e l l a , i n t h e f o r m o f a s m a l i n v e r t e d " v " .

T h i s s e q u e n c e r e s u l t s i n a f a s t e r d e t t a c h m e n t o f s k i n ,

a v o i d i n g t r a u m a a n d , s o m e t i m e s , s k i n s c r u b b i n g a t t h e

c o l u m e l l a p o i n t . A l s o , i t i s v e r y i m p o r t a n t t h a t , i n s o m e

c a s e s , e v e n b e i n g s c h e d u l e d a n o p e n r h i n o p l a s t y , d e f o r m i t y

c a n b e t r e a t e d o n l y b y ft m a r g i n a l i n c i s i o n , b e i n g n o t

n e c e s s a r y f r e e c o l u m e l l a i n i t s e n t i r e t y .

DIAGNOSIS AND TREATMENT

S i x t y - t w o c a s e s o f e n d o n a s a l d e f o r m i t i e s w e r e

t r ~ a t e d ..'D e f o r m i t i e s c a n b e c l a s s i f i e d a s f o l l o w s :

Figure 1A -

P re o p e ra tiv e s e m b la n c e o f th e p a tie n t w ith e n d o n a s a l a s y m m e try , s a d d le n o s e

1 . E x c e s s i v e r e s s e c t i o n

2 . A s y m m e t r i c r e s s e c t i o n

3 . I n s u f f i c i e n t r e s s e c t i o n

4 . T o t a l r e s s e c t i o n

I n 1 0 0 % o f t h e c a s e s a s y m m e t r i c r e s s e c t i o n w a s

o b s e r v e d , e v e n i n t h e t o t a l o n e s , d u e t o d i f f e r e n c e s i n t h e

r e m a i n i n g s t u m p .

T r e a t m e n t s w e r e c l a s s i f i e d i n t w o g r o u p s :

1 . I n s u f i c i e n t a n d a s y m m e t r i c c a s e s : w e t r i e d t o f r e e

a l l a r c a r t i l l a g e s i n i t s e n t i r e t y , s i n c e t h e m e d i a l .c r o s s t i l l

e x t r e m e t y ; a p p r o a c h i n g b o t h c a r t i l l a g e s , s i d e b y s i d e , a

c o m p l e t e l y s y m m e t r i c a l r e s s e c t i o n i s p o s s i b l e t o b e d o n e .

Figure 1 B -

A s p e c t a fte r e n d o n a s a l e x p o s itio n , h ig h a s y m m e try o f th e a la r c a rtilla g e s , rig h t a la r c a rtilla g e s e c c io n e d rig h t a b o v e

d o m u s

Figure

1 C -

A s p e c t o f th e a la r c a rtilla g e re s to ra tio n w ith a la r c a rtilla g e le ft o v e rs

-.7 3 0

Figure 1 D -

F in a l a s p e c t o f th e p a tie n t, 6 m o n th s a fte r s u rg e ry

Figure 2A -

P r e o p e r a t i v e a s p e c t , w i t h p i n c e d e n d o n a s a l

Figure 2C -

A s p e c t o f t h e g r a f t s u t u r e s i n t h e m e d i a l s t u m p o f t h e a l a r c a r t i l l a g e s

2. In the excessive

and total ressection

cases,

we

reccur on to grafts of the remaining

allar cartillages,

septal

cartillages

or conchal ones.

We frequently

obtain

leftover

fragments

from the

more lateral portion, that are dissected

and sutured to the

portion

where

an excessi ve ressection

has been done.

Suture

is done with monofilar

nylon thread

6.0 (Fig. 1

A,B,C and D).

When

septal cartillage

is chosen,we

use fragments

of approximately

2.5 x lcm, carved to reproduce

the allar

cartillage

(Fig. 3 A,B,C,D,E,F,G).

Carefully,

cartillage

is

divided in its whole espessure. We observe that the 2 sheets

obtained present a convexity, rigorously in the same format

as the allar cartillages

(Fig.3 A and B).

Figure 28 -

C o n c h a l c a r t i l l a g e s c a r v e d , r e p r o d u c i n g a l a r c a r t i l l a g e f o r m

Figure 20 -

F i n a l a s p e c t o f t h e e n d o n a s a l , 6 m o n t h s a f t e r s u r g e r y

These cartillage

sheets are sutured on the remaining

cartillage

stump (Fig.3 C,D,F).

In order to get symmetric

and, .mainly,

the same

resistance,

stumps must be withered

to the same .level, so

as the suture graft. This procedure

avoids

distortion

and

uneveness

of the future endonasal.

..

Conchal

graft is obtained

through

a retroauricuiar

incision

and wide dettachment

of the conchal

cartillage.

Two convex

and symmetric

portions

are chosen

and

properly

withered.

Conchal

cartillages,

being very thick,

need to be carved,

mainly

in the edges,

where they are

slender (Fig.2 A,B,C,D).

In some cases, in order to avoid very large ends, some

incisions

may be done to decrease

the spring resistence.

R E S U L T S

E n d o n o s e w a s r e s t o r a t e d i n a l l o f t h e s u r g e r i e s

p e r f o r m e d . S m a l l a s y m m e t r y w a s o b s e r v e d i n 2 c a s e s . I n

o n e o f t h e m , w h e r e a s i m u l t a n e o u s d o r s a l g r a f t i n g w a s

p e r f o r m e d , a n i n f e c t i o n o c c u r r e d , b u t w a s s a t i s f a c t o r i l y

s o l v e d b y a n t i b i o t i c o t h e r a p y .

D IS C U S S IO N

R h i n o p l a s t y w i t h e x t e r n a l i n c i s i o n i n t r o d u c e d n e w

a s p e c t s i n t h e t r e a t m e n t o f s e c o n d a r y n o s e d e f o r m a t i o n s ,

m a i n l y i n w h a t r e f e r s t o t h e e n d o n o s e s t r u c t u r a l

F ig u r e 3 A - F r a g m e n t o f s e p ta l c a r tilla g e b e in g b ip a r te d to o b ta in c a r tilla g e g r a ft fo r th e w in g o f th e n o s e . T h e tw o c a r tilla g e s h e e ts

s h o w s id e c u r v e te n d e n c y , b e c o m in g c o n v e x e d

F ig u r e 3 C - A s p e c t o f e n d o n a s a l p la c in g , b e in g p r e p a r e d fo r s u tu r e

c o m p o n e n t s . C o m p l e t e v i e w o f e l e m e n t s " i n s i t u " e n a b l e s

p r e c i s e a n a t o m i c d i a g n o s i s a n d t h e l a r g e e x p o s i t i o n o f t h e

s u r g i c a l a r e a e n a b l e s s u r g i c a l p r o c e d i n g s , d i f f i c u l t t o b e

p e r f o r m e d b y t h e e n d o n a s a l u s u a l w a y s . A s s e s s m e n t o f

l o s s e s a n d c a r t i l l a g e g r a f t o n t h e w i n g s c a n b e d o n e

s y m m e t r i c a n y .

T h e t h r e e m e t h o d s a p p l i e d f o r t h e e n d o n a s a l

r e s t o r a t i o n s h o w e d t o b e v e r y e f f i c i e n t . I n s m a l l f a i l u r e s ,

u s e o f s m a l l f r a g m e n t s o b t a i n e d f r o m l e f t o v e r s o f t h e a l l a r

c a r t i l l a g e i t s e l f , i n t e r m s o f r e s u l t s , w a s t h e e a s i e s t m e t h o d

a n d t h e b e s t o n e , d u e t o t h e s t r u c t u r e a n d c h a r a c t e r i s t i c s

o f t h i s c a r t i l l a g e .

C o n c h a l c a r t i l l a g e , d u e t o h i g h e r t h i c k n e s s a n d l e s s

f l e x i b i l i t y , e v e n m o d u l a b l e , r e s u l t e d i n a s l i g h t l y b u l b o u s

a n d f i r m e n d o n a s a l .

F ig u r e 3 8 - S e p ta l c a r tilla g e d iv id e d in th e m id d le , s h o w in g th e

c o n v e x fo r m th e y a c q u ir e

F ig u r e 3 D - S e p ta l c a r tilla g e s u tu r e d to m e d ia l c r o s s o f th e a la r

c a r tilla g e

Figure

3E -

A s p e c t a fte r th e g ra ft s u tu re o n th e c a rtilla g e o u s s tu m p

Figure 3F -

P re o p e ra tiv e a s p e c t o f p a tie n t s h o w in g th e e n d o n a s a l p in c e m e n t. C a rtilla g e m is s in g o n th e la te ra l a re a

REFERENCES

1 . G O O D M A N , W .S . - E x te rn a l a p p ro a c h to rh in o p la s ty .

Can

J

Otolaryngol

2 :2 0 7 ,1 9 7 3 .

2 . G O O D M A N , W .S . - R e c e n t a d v a n c e s in e x te rn a l rh in o p la s ty .

J

Otolaryngol

1 0 :4 3 3 ., 1 9 8 1 .

Figure 3G -

P o s to p e ra tiv e a s p e c t, a fte r re s to ra tio n w ith s e p ta l c a rtilla g e g ra ftin g

3 . P A D O V A N , I. - E x te rn a l a p p ro a c h to rh in o p la s ty

(d e c o rtic a tio n )

Ann Otol Rhinol LaryngoI3-4:

3 5 4 , 1 9 6 6 .

4 . R E T H I, A . - O p e ra tio n to s h o rte n a n e x c e s s iv e ly lo n g n o s e .

Rev Chir Plast

2 :8 5 , 1 9 3 4 .

5 . S E R C E R , A .: - D e k o rtic a tio n d e r N a s e .

Chir Maxillofac

Plast

1 : 1 4 9 , 1 9 5 8 .

6 . S H E E N , J . -

Aesthetic Rhinoplasty.

M o s b y , 1 9 8 7 .