Aesth. Plast. Surg. 28:375380, 2004 DOI: 10.

1007/s00266-004-4031-4

Nasal Middle Vault Support: A New Technique

M. S. Fayman, M.D., and E. Potgieter, M.B.B.C.H.
Johannesburg, South Africa

Abstract. A novel technique for maintaining internal nasal valve anatomic and physiologic integrity at the time of hump reduction is proposed. The procedure involves mobilizing the anterior edge of the upper lateral cartilage after submucosal dissection. Reduction of the anterior border of the septal cartilage and reconstruction of the middle vault of the nose is accomplished by placing the upper lateral cartilage medial border on the reduced edge of the septum using a vest-over technique. The technique was successfully used for 32 nonconsecutive patients over a 4-year period. Key words: Inner nasal valveMiddle nasal vaultNasal dorsumNasal reconstructionNoseRhinoplasty

Surgical Technique The new procedure is performed with the patient under general anesthesia or under intravenous sedation. Local anesthesia of the nose is administered in a routine manner using lignocaine 2% mixed with adrenaline 1:80,000. Two-ribbon gauzes soaked in 1.5 to 2 ml of cocaine are placed in the nostrils (one in each side). Skeletonization of the middle and proximal vaults of the nose is accomplished with either the closed or open approach using a transcartilaginous incision, with possible extension into a transxion incision. A small elevator is used to separate the mucosa from both the posterior surface of the upper lateral cartilage and the anterior septum. This approach allows for a complete submucosal dissection. Rasping of the bony dorsum is accomplished using the appropriate rasps. A small elevator then is used to separate the upper lateral cartilage from the septum (Fig. 1a). The anterior edge of the cartilaginous septum is trimmed using either angled scissors or a #12 blade (Fig. 1b). The medial edge of the upper lateral cartilage then is placed in a vest-over manner so that the one cartilage lies on the cut edge of septum and the contralateral cartilage lies anterior to the medial edge of the rst cartilage (Fig. 1c and d). Tip work and osteotomies then follow in a routine manner. Fixation of the upper lateral cartilages to each other or to the septum is needed only when the overlap of the cartilages is minimal (less than 1 mm). We base this statement on our experience with one case of collapse early in the series.

The importance of the inner nasal valves in regulating airow through the nose has long been recognized. Several surgical techniques [1,35,7,12,13,15] were developed to maintain the integrity of the valve or to restore it when it has been rendered incompetent, usually as a result of previous surgery. Other sequelae of nasal hump reduction include long-term dorsal irregularities, excessive narrowing of the middle vault, inverted V deformity related to the overresection of upper lateral cartilages and over- or underresection of the dorsal hump. A new technique is proposed to maintain the integrity of the valve during dorsal hump reduction in both cosmetic and reconstructive rhinoplasties. This technique also is designed to reduce the incidence of dorsal irregularities, excessive narrowing of the middle vault, and prevention of the inverted V deformity.

Material and Methods

Correspondence to M. S. Fayman, M.D., Rosebank Clinic, Parklands 2121, P.O. Box 1708 Johannesburg, South Africa; email: drfayman@mweb.co.za

Over a 4-year period ending June 2003, 32 nonconsecutive patients (22 females and 10 males) underwent

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Fig. 1. (a) Top left: Upper lateral cartilages are separated from the septum using a small elevator. (b) Top right: Cartilaginous septum is trimmed. (c) Bottom left: Medial edges of upper lateral cartilages are ready to be overlapped. (d) Bottom right: Medial edges of upper lateral cartilages are overlapped in a pants-over-vest manner.

her nose at the age of 11 years, which had been managed conservatively. She reported that her left airway was blocked more than the right one, particularly during the night. Physical examination showed a high and wide bridge, deviation of the nose to the right beginning at the area of the middle vault, poor tip support but a good columellaalar relation, dorsal osteocartilaginous hump, turbinate hypertrophy, and septal deviation to the right. Surgical steps included a transcartilaginous incision extending into a right transxion incision. Rasping of the dorsum was performed, followed by resection of the cartilaginous dorsum using the aforementioned technique. An entirely extramucosal technique was accomplished. The cephalad portion of the lower lateral cartilage then was removed and the caudal septum trimmed. The medial crura were sutured to the distal septum to obtain elevation and rotation of the tip. A septoplasty was performed using a scoring technique to obtain correction of the deviation. The patients preoperative results and her postoperative results 14 months after surgery are illustrated in Fig. 2.

Case 2 surgery using this technique. Of these 32 patients, 20 were primarily rhinoplasty patients and 12 were either posttraumatic or secondary rhinoplasty patients. Their ages ranged from 16 to 52 years. The follow-up period ranged from 6 months to 4 years (mean, 23 months). This technique was not selected for patients with upper lateral cartilage irregularities such as anterior septo deviation or extensive scarring in the upper lateral cartilageanterior septal junction as a result of previous surgery in this area. Results All the patients reported either improvement or persistence of their airway patency. None reported increased airway obstruction after surgery. Two patients expressed concern about irregularities at the osteocartilaginous junction. Neither desired a surgical revision. Surgical revision was required for one patient with a persistent middle vault deviation. Infection occurred in one patient, which responded to antibiotic treatment. Four illustrative cases are presented. Case 1 A 28-year-old woman requested reduction of her nasal dorsal hump. She had experienced fracture of A 50-year-old woman reported supratip fullness and requested general improvement of her nose. Physical examination showed asymmetry of the supratip, upper lateral cartilages, and the domes; the left lower lateral cartilage substantially higher than the right one; and a broad bridge as well as a relatively low radix. The patient, however, desired no change for this area of her nose. A deection of the caudal septum to the left was noted as well. The columella alar margin relation was appropriate and, the columellalabial angle was noted to be 90. The following surgical steps were performed. A transcartilaginous incision was extended to a transxion incision on the right. The cephalad portion of the lateral crus of the lower lateral cartilages was resected on each side, leaving a margin of 8 mm. The caudal septum was exposed through the right transxion incision. The right footplate was resected longitudinally to allow for retraction of the right side of the columella. Conservative dorsal skeletonization was followed by correction for the asymmetry of the lower lateral cartilages using an on-lay lateral crus graft. The supratip fullness was corrected using the aforementioned technique, including release of the upper lateral cartilages and shaving of the anterior cartilaginous septum. A septoplasty was performed by scoring the left side of the septum (allowing deection to the right) and excising an osteocartilaginous spur from the base of the septum. The middle vault was reconstructed using the upper lateral cartilages placed in a vest-over position. A low-to-low osteotomy also

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Fig. 2. Case 1. Top line: Preoperative. Bottom line: Postoperative.

Fig. 3. Case 2. Top line: Preoperative. Bottom line: Postoperative.

was performed. Figure 3 shows the patients photos before and 1 year after surgery. Case 3 A 28-year-old man presented with nasal deviation and airway obstruction. The patient had undergone two prior nasal operations between the ages of 6 and 11 years for correction of a deviated septum. Physical examination showed the following: a C deformity of the nose with curvature occurring at the middle vault,

A droopy tip, thick skin, a substantial dorsal hump, and an obstructed right airway. The following surgical steps were performed. An open rhinoplasty was performed. Septal cartilage graft 25 mm long and 8 mm wide was harvested. An osteocartilaginous spur on the nasal oor was resected. A hump reduction was performed using a rasp for the bony part. The upper lateral cartilage was separated from the dorsal septum, which then was reduced as described previously. A unilateral spreader graft was added (straightened by scoring), and the upper lateral cartilages were placed over the spreader

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Fig. 4. Case 3. Top photograph: Preoperative. Bottom photograph: Postoperative.

graft. The tip received an interdomal suture, and the medial crura was sutured to a columella strut. No trimming of the lower lateral cartilages was done. A submucosal turbinectomy followed. The result before surgery and 18 months later are depicted in Fig. 4. A substantial functional improvement was reported by the patient. Case 4

medial crura were sutured to the caudal septum using 5-0 colorless nylon. A turbinectomy also was performed. A low-to-low osteotomy was performed using a 2-mm straight osteotome and a percutaneous technique. Images of this patient before surgery and 1 year postoperatively are shown in Fig. 5. A substantial symptomatic improvement was reported. Discussion

An 18-year-old student requested correction for the dorsal hump of his nose. Physical examination showed a substantial hump. The nose deviated to the right, including a C deformity at the middle vault. A wide tip, relatively short nasal bones, and good columellalobule and commellaalar relations also were observed. At surgery, the following surgical steps were performed. Right and left transcartilaginous incisions were made. The left incision continued into a transxion incision. Moderate skeletonization of the dorsum followed, and submucosal tunneling deep to the upper lateral and nasal bones was performed. The bony dorsum was rasped, followed by separation of the junction of the upper lateral cartilages from the septum and dorsal shaving to the appropriate level. The upper lateral cartilages then were repositioned over the reduced septum. The cephalad portion of the lower lateral cartilages was trimmed, leaving a margin of 8 mm. A crushed cartilage graft from the cephalic trim was placed over the tip. Spreader grafts were constructed from septal cartilage to maintain the reduced septal curvature. The lower lateral cartilages were placed over the spreader grafts. The

The importance of the nasal valves has been reviewed elsewhere [1,35,7,12,13,15]. The internal nasal valve oers the highest resistance to airow in the nasal passage, and therefore plays an important role in nasal functions such as humidication, temperature regulation, and ltration. The junction between the upper lateral cartilage and the septum usually is 10% to 15% [2,9]. Findings also have shown the internal nasal valve to be the single most important factor contributing to nasal obstruction. The most common cause of secondary inner nasal valve incompetence is nasal surgery, particularly dorsal hump reduction. This surgical maneuver often violates the junction between the septum and upper lateral cartilage, resulting in a loss of the normal 10 to 15 angle between the upper lateral cartilage and the dorsal septum by scarring in that area, and also in a webbing eect of the mucosa. Several authors, recognizing the problem, have oered a variety of solutions. Goode [5] proposed replacement of vestibular skin and cartilage with composite grafts. Adamson [1] proposed excision of the scar and replacement with a graft. The skin graft

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Fig. 5. Case 4. Top photograph: Preoperative. Bottom photograph: Postoperative.

was harvested from the upper lids, postauricular skin, or buccal mucosa. Other authors have oered similar solutions using either one or two surgical stages [8]. The most popular solution is Sheens [12,13] spreader graft, which is used for both primary or secondary cases. Stucker and Hoasjoe [14] proposed a conchal cartilage graft over the dorsum through which the upper lateral cartilages can be secured to increase the angle of approach to the septum. A suturing technique to increase cross-section area of the valve was proposed by Park [10]. This article proposes a novel idea of maintaining the inner nasal valve integrity while performing nasal hump reduction during primary or secondary rhinoplasty. The technique uses submucosal dissection, separation (or disarticulation) of the medial border upper lateral cartilages from the anterior septum, and reduction of the dorsal hump by cutting of the anterior border of the cartilaginous septum and repositioning of the medial borders of the mobilized upper lateral cartilages on top of each other and on the reduced septal cartilage. This technique preserves the anatomic integrity of the upper lateral cartilage as well as the 10 to 15 normal angle between the upper lateral cartilage and the anterior septum. Regarding this technique as simple as anatomically and physiologically sound, we propose it as a simple alternative to techniques previously described. In cases of primary and secondary nasal dorsal hump reduction, the technique oers additional advantages of covering irregularities or small deformities of the anterior edge of the reduced septal cartilage. It also aords easy access to the septum during open or closed septoplasty. The limitations of the technique, in our view, are the following. A deformity of the medial edge of the upper lateral cartilages would require separate

attention. This surgical maneuver is, however, easily attainable through the exposure oered by this technique. Extensive dorsal reduction would require trimming of the medial edge of the mobilized upper lateral cartilage. Extensive scarring in the inner nasal valve area would require further cartilaginous support in a form of a spreader graft. Spreader grafts also would be the technique of choice in cases of anterior septal cartilaginous deviation. Our technique aords direct control of the height and the shape of the dorsal line and oers better control than the mid septal strip resection method of Ishida et al. [7,11]. They report a 15% residual hump incidence requiring secondary revisions. They also report that their technique broadens the nasal dorsum. These drawbacks are specically addressed by our technique. The dorsal line can be sculptured under direct control, and the width of the middle vault is specically managed under direct vision. Our technique can be considered an alternative to the technique described by Gunter and Rohrich [6,11]. The positioning of the upper lateral cartilage anterior to the reduced septal cartilage reduces the risks for excessive narrowing of the middle vault resulting from overzealous trimming of the medial edge of the upper lateral cartilage. It also diminishes the inverted V deformity resulting from overresection or avulsion of the upper lateral cartilage. The technique described by Park [10] is designed to increase a aring of upper lateral cartilages, and in so doing, to increase the cross section of the inner nasal valve area, allowing improved airway ow through the nasal airway. Our technique likely reduces the risk for a diminished cross-section area of the inner nasal valve area (in either primary or secondary rhinoplasty), but it relies on normal conguration of the upper lateral cartilages before surgery. Although we

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have no experience with the Park technique, it seems that his technique could complement and augment our technique.

References
1. Adamson JE: Constriction of the internal nasal valve in rhinoplasty: Treatment and prevention. Ann Plast Surg 18:114, 1987 2. Anand, VK, Isaacs, R (1994) Nasal physiology and treatment of turbinate disorders In: Rees, TD, LaTrenta, GS, Stilwell, D (eds.), Aesthetic Plastic Surgery, Saunders, Philadelphia 3. Constantian MB: The incompetent external nasal valve: Pathophysiology and treatment in primary and secondary rhinoplasty. Plast Reconstr Surg 93:919, 1994 4. Constantian MB, Clardy RB: The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Plast Reconstr 98:38, 1996 5. Goode RL: Surgery of the incompetent nasal valve. Laryngoscope 95:546, 1985 6. Gunter JP, Rohrich RJ: The external approach for secondary rhinoplasty. Plast Reconstr Surg 80:161, 1987

7. Ischida J, Eshida LC, Ishida LH, Vieira JCR, Ferreira MC: Treatment of the nasal hump with preservation of the cartilaginous framework. Plast Reconstr Surg 103:1729, 1999 8. Karen M, Chang E, Keen MS: Auricular composite grafting to repair nasal vestibular stenosis. Otolaryngol Head Neck Surg 122:529, 2000 9. Kimmelman CP: The problem of nasal obstruction. Otolaryngol Clin North Am 22:263, 1989 10. Park SS: The aring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg 101:1120, 1998 11. Rohrich RJ: Discussion on treatment of the nasal hump with preservation of the cartilaginous framework. Plast Reconstr Surg 103:1734, 1999 12. Sheen JH: Spreader graft: A method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 73:230, 1984 13. Sheen JH: Spreader graft revisited. Perspect Plast Surg 3:155, 1989 14. Stucker FJ, Hoasjoe DK: Nasal reconstruction with conchal cartilage: Correcting valve and lateral nasal collapse. Arch Otolaryngol Head Neck Surf 120:653, 1994 15. Sullivan PU, Varma M, Rozelle AA: Optimizing bonegraft nasal reconstruction: A study of nasal shape and thickness. Plast Reconstr Surg 97:327, 1996