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Rhinoplasty Bizrah: Septorhinoplasty Incisions and Primary Manoeuvres

March 28, 2017 by basharbizrah0

Incisions are essential in order to approach, reach modify and correct the nasal structure in septorhinoplasty. The septorhinoplasty incisions have a special importance. The intercartilagenous incisions divide the attachment of lateral crus to the upper lateral cartilage and the transfixion incision divides the attachment of the medial crura to the caudal septum. This results in loss of tip support and its unpleasant effects of dropped tip, pollybeak, hanging columella and wider nostrils. Therefore, compensatory means in order to support the tip (new dome creation, or the modified vertical dome division with columellar and tip grafts) are essential manoeuvres following our rhinoplasty incisions.

The choices of incisions varies according to the clinical situation. We currently use the following incisions:

– Intercartilagenous incision – 100%
– Transfixion incision – 95%
– Marginal incision – 90%
– Alar wedge incision – 20%
– Transcolumellar incision – 2%

Types and Indications:

    1. Transfixion incisions:
      1. Modified transfixion incision:
        Carried out around the superior septal angle and extended down one to two cm inferiorly. It is indicated in cases for hump corrections or mild tip bulbousity where there is adequate tip projection and rotation. (Figs. 5 – 1,2,3)

 

      1. Hemitransfixion incision:
        Carried out around the superior septal angle down along caudal septal margin beyond the middle crura-septal attachment. Indicated in cases of hump correction, mild bulbousity and septal deviation where there is adequate tip projection and rotation. (Fig. 17-9)

 

    1. Complete transfixion incision:
      Carried out bilaterally (through and through) around the superior septal angle and down along caudal septal margin beyond the medial crura-septal attachment but stops above the nasal spine. It is indicated in delivery of the alar cartilage, corrections of hump and septal deviation. Compensatory measures (new dome creation, scoring, suture fixation or Bizrah’s modification of vertical dome division with columellar and tip grafts and septocolumellar sutures) should be considered following this type of incision in order to support the tip and achieve adequate tip projection and definition.

 

Fig. 5 – 1. Septorhinoplasty incisions
  1. Intercartilagenous incision: is made at the mucosal-vestibular skin between upper and lower cartilages
    and carried out medially around the superior septal angle to meet the transfixion incision.
  2. Transfixion incision: Carried out around the superior septal angle and extend down along the caudal
    septal margin of two cm.
  3. Marginal incision: it follows intranasally the caudal margin of the lower latreral cartilage from mid-
    columella to mid-alar on the vestibular skin.
  4. Transcolumellar incision: It connects the two marginal incisions at a mid-columellar point in a V or Z design.

 

Fig 5 – 2. Intercartilagenous and transfixion incisions. The intercartilagenous incision is made at the vestibulomucosal junction beween upper and lower latreral cartilages from a lateral point and carried out medially around the superior special angle and down along the caudal septum margin in a hemi or complete transfixion incision.

 

  1. Intercartilagenous incision
    The intercartilagenous incision is made at the mucosal vestibular skin between upper and lower cartilages from the most lateral point and carried out medially around the superior septal angle and down along the caudal septal margin in hemitransfixion incision. (Figs. 5 – 1,2,3)
  2. Marginal incision
    It follows the inferior margin of the lower lateral cartilage from about mid-columella to mid-alar on each side (Figs. 5-1,2,3,). It may as indicated extend from the medial crural foot plate to the pyriform aperture. The skin incision at the columella is made one mm behind the caudal edge at the intermediate and lateral crura to prevent postoperative scarring and alar margin notching and retraction. (Fig. 17-12)
  3. Transcolumellar incision (external incision)
    It connects the two marginal incisions at a mid-columellar point in a V or Z design.
    It may be indicated in:
    Revision rhinoplasty
    Severely crooked noses
    Cleft noses
    Surgeons with outstanding skills rarely need to employ the external incision. It is employed in only 2% of our cases. (Fig 5-1D and Fig. 17-27)
  4. Transcartilagenous incision: Reserved for cases of mild bulbousity with strong alar cartilages and adequate tip projection and rotation. The incision is made horizontally into the vestibular skin and lateral crus, the cephalic portion of the lateral crus is then excised with its connected fibro fatty tissue, but with preservation of vestibular skin. The author does not recommend the use of this blind excision of the cephalic lateral crus and feels that it should be applied only in cases of mild bulbousity with strong cartilages, adequate tip projection and rotation. Even so, in these situations, the author strongly recommends the use of columellar strut through a small mid-columellar incision in order to support the tip, following the division of the soft tissue connection between the lateral crus and upper lateral cartilage. Although this technique is not suitable for use with patients in the Middle East, it remains popular in Northern European countries and Canada. Unfortunately, many surgeons in the Middle East do not differentiate between the characteristics of the tip cartilage and soft tissue between such races. Many of the people from the Middle East have what is called the heavy tip (thick skin, subcutaneous fat and soft cartilage), which is predisposed for postrhinoplasty loss of tip support and its unpleasant effects such as dropped tip, pollybeak and wider nares.
    1. Alar wedge incision:
      Indications and techniques are discussed fully in the chapter on Alar Wedge excision.

Fig. 5 – 3. Inttercartilagenous, transfixion and marginal incisions

 

Hints

  1. Keep the incision sharp and delicate and avoid irregularities and cutting across the edges.
  2. Avoid mucosa and vestibular skin excisions to prevent vestibular stenosis.
  3. Do not extend the intercartilagenous incision too much laterally in order to avoid dividing the attachment in the cartilage to the pyriform aperture which may cause valve collapse and pinching.
  4. Do not extend the transfixion incision too much downwards to the nasal spine to avoid excessive loss of tip support.
  5. Keep your marginal incision close to the caudal margin of the intermediate and lateral crus to avoid notching and scarring of the alar rim.
  6. Close your marginal incision meticulously using 4/0 Dexon. Stitch skin to skin, never cartilage to skin. (Fig. 5-4)
  7. Position your marginal incision sutures obliquely in a way high on the alar rim and low on the lateral crus skin in order to pull up the lateral crus to the alar rim to prevent notching, pinching, retraction and nares asymmetry.
  8. Close your transfixion incision by buried 4/0 Dexon sutures. Trim redundant soft tissue to avoid hanging columella and to avoid later pocket formation and collection of crusts and its unwanted smell. (Fig. 5-4)
  9. Support the buried Dexon suture of the transfixion incision by two septocolumellar sutures to preserve and support the tip projection.
  10. Avoid tight strips around the tip which may push the rim in, predisposing for notching
  11. Always remember that incisions divide the intercartilagenous ligaments and tissue connection, predisposing for the loss of tip support. Therefore, compensatory measures (new dome creation, suture fixation, scoring, columellar strut, tip graft, septocolumellar suture) are mandatory to achieve tip projection, rotation, elevation, definition, refinement and symmetry.

 

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