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British Journal of Oral and Maxillofacial Surgery 53 (2015) 44–48

Available online at www.sciencedirect.com

se of aesthetic rhinoplasty procedures in reconstructiveasal surgerylireza Ghassemi a,∗, Albert Rübben b, Behnam Bohluli c,rank Hölzle a, Mehrangiz Ghassemi d

Department of Oral, Maxillofacial of Surgery, University Hospital of RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, GermanyDepartment of Dermatology, University Hospital of RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, GermanyCraniomaxillofacial Research Center, Azad University of Tehran, Tehran, IranDepartment of Orthodontics, University Hospital of RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany

ccepted 15 September 2014vailable online 5 November 2014

bstract

esection of cancer often involves the excision of underlying hard tissue, and some procedures in aesthetic rhinoplasty can be used ineconstructive nasal surgery to increase the margin of safety while still achieving an acceptable aesthetic and functional outcome. We havesed techniques from aesthetic rhinoplasty to shape the nasal framework. Osteotomy and formation of the tip were used in 17 patients withefects (ranging from 1 to 3.5 cm in size) from the nasal root to the tip of the nose. After the underlying bony or cartilaginous framework,r both, had been removed, the resulting open roof deformity had to be corrected by osteotomy of the bony nasal wall and the tip shapedy excision and suturing, including insertion of the tip graft and columellar strut graft. After this, and narrowing of the nose, the defectas smaller and could be closed with local tissue without tension. There were no deformities in the contour, and patency of the airwayas maintained. Patients were satisfied with both the aesthetic and functional results. Although the margin of safety was increased, shaping

he nasal framework reduced the size of the defect, which allowed tension-free closure with a local flap. The operation requires a thoroughnowledge of procedures used in aesthetic rhinoplasty.

2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

eywords: Tumour excision; Hump removal; Osteotomy; Tip-forming; Local flap

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asal reconstruction has always been a challenge for recons-ructive surgeons, and the use of a local flap provides the

est options for colour, texture, and thickness. A successfuleconstruction of the bony and cartilaginous scaffold shouldchieve a harmonious appearance.

∗ Corresponding author. Klinik für Zahn-, Mund-, Kiefer- und Plastis-he Gesichtschirurgie, Universitätsklinikum RWTH-Aachen, Pauwelsstr.0, 52074 Aachen, Germany. Tel.: +49 241 8088247; fax: +49 2418082430.

E-mail address: aghassemi@ukaachen.de (A. Ghassemi).

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ttp://dx.doi.org/10.1016/j.bjoms.2014.09.011266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Pu

A simple improvement in the nasal contour can have anppreciable impact on the overall appearance of the nosend on the patient’s self-confidence. Refinements have beenuggested to minimise any noticeable deformity,1,2 but theomplexity of nasal contours is a challenge that demands theefinement of existing procedures.3,4

During past decades there have been considerabledvances in reconstructive surgery. Existing methods haveeen refined and new methods have been developed,

ncluding the use of microsurgical tissue transfer.5–8 Thentroduction of aesthetic nasal “subunits”, although contro-ersial, has contributed greatly to these refinements.9–12

blished by Elsevier Ltd. All rights reserved.

A. Ghassemi et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 44–48 45

Fig. 1. Left lateral view of a 58-year-old woman after excision of a basal cellc

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Fig. 2. Photograph of the same patient after excision of the tumour with anao

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sctle pressure with the fingers. The stability of the nasal wallwas maintained and tearing of the nasal mucosa avoided.

arcinoma from the tip of her nose (published with the patient’s permission).

Many variables, including the size and site of the defect,he shape of the nose, and the laxity of the covering skin,re important determinants of the choice of reconstructiveechnique. Osteotomy of the nose is an essential step in aes-hetic rhinoplasty to correct an open deformity of the nasaloof and an irregular nasal wall, or to narrow the width of theasal base.13 Many procedures have been developed to shapehe tip of the nose.14,15 Excision of the tumour and raising aap permit wide exposure of the nasal bones and cartilage.his allows exact manipulation of the nasal framework underirect vision.

Here we present our clinical experience in the adjust-ent of the nasal framework after excision of a tumour using

steotomy and tip-forming techniques. The method was usedo increase the margin of safety and reduce the size of theasal defect to allow primary closure of the residual defect.

atients and methods

e studied 17 patients with malignancies of the nose (7 mennd 10 women, mean age 65 (range 37–83) years). Afteresection of the tumours with clear margins, the size of theefects, which were on the nasal dorsum from the base tohe nasal tip, ranged between 1 and 3.5 cm. This includedesection of the underlying bony or cartilaginous (or both)ramework of the nose. For 5 patients we used unilateral orilateral advancement flaps from the cheek. Four had bilobedaps. We chose tissue from the nasal dorsum for 8 patientsFigs. 1 and 2). Tension-free closure was achieved satisfac-orily in all. We used a nasal osteotomy to correct the open

oof deformity, a large carbide burr was used to flatten theasal base, and a small diamond burr was used for the lateralsteotomy. The procedure was done under local anesthesian 9 patients, and under general anaesthesia in 8.

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dequate margin of safety. The design of the flap is marked on the dorsumf the nose (published with the patient’s permission).

esults

good aesthetic outcome was achieved in all 17 patients witho major complications. In the cases where an advancementap from the cheek was considered, secondary debulkingas required to improve the nasolabial region. An open roofeformity, resulting from removal of the hump (Fig. 3), wasorrected by lateral osteotomy of the bony nasal wall (Fig. 3).he osteotomy was easily done with a diamond burr after thelanned local flap had been dissected. This allowed accu-ate and precise control of the path of the osteotomy and theositioning of the bony lateral wall under direct vision. Thispproach allows various types of nasal osteotomy – lateral,edial, or transverse – as necessary.The osteotomy line was smooth and allowed a predictable

plit exactly as planned, and there were no unfavourable oromminuted fractures. The infracturing was achieved by gen-

ig. 3. After flap dissection, excision of the hump, and lateral osteotomyade with a diamond burr.

46 A. Ghassemi et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 44–48

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ahaisooAtathe aesthetic outcome. Use of the nasal mucosa has also

ig. 4. Photographs taken after 8 months: (a) patient’s left lateral view, (b)he patient’s permission).

Lateral osteotomy, followed by digital infracturing, nar-owed the width and reduced the size of the defect. Inddition, the reduction of the cranial part of the lower lateralartilage and the tip-suturing techniques that we used alsoeduced the size. These procedures allowed the tension-freeeconstruction of the defect by local procedures (Fig. 4a–c).ll patients were satisfied with the result, whereas preopera-

ively they had been anxious about a possible deformity.

iscussion

asal reconstruction comprises controlled changes in thekeletal support structures and the soft tissue envelope to

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’s right lateral view, and (c) the patient’s view from below (published with

chieve the desired results. Improvement in the nasal contouras an appreciable favourable impact on the patients’ overallppearance and self-confidence. There has been an increas-ng demand for optimal aesthetic and functional outcomes,o various techniques have been suggested for replacementf the soft tissue lost after resection of the cancer, dependingn the size and site of the defect and the tissue involved.2–8

dvances have been made during the past decade to achievehe best possible results in reconstructive rhinoplasty. Burgetnd Menick introduced the “subunits” philosophy to improve

10

ptimised the result of reconstruction in perforated defects.16

evertheless, there is a need for further improvement in theesults, and simplification of the procedure.

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A. Ghassemi et al. / British Journal of O

A small residual deformity of the nose can be seen, butven a small improvement can have a favourable impact onhe patient’s quality of life.1,2 If the principles of aestheticnd functional nasal surgery are followed, it can result in anutstanding repair, so the use of the appropriate techniqueill help to achieve the desired result.3,4

Skeletal support of the nose provides the main aestheticnd functional requirements of nasal reconstruction. It ishe framework that provides the support and shape of theovering soft tissue,5 and the restoration of the nasal con-our is integrally related to the composition and design ofhe nasal framework. The principles of reconstruction of thekeletal support are similar to those of aesthetic rhinoplasty,nd we have shown the importance of different techniqueshat are commonly used in aesthetic rhinoplasty to shape theasal framework. In addition, these techniques can be usedo reduce the size of the defect, allow easier replacement ofissue, and help to increase the margin of safety.

An alteration in the width of the nose by lateral osteotomy,hich is a usual part of aesthetic rhinoplasty, can be used in

econstructive nasal surgery.13 It is an integral part of rhino-lasty, and can be used to reshape the lateral contour, narrowhe base, realign the dorsum, and correct an open roof defor-

ity. Various methods and instruments have been introducedor this purpose.17–22 The osteotomy should be controllable,redictable, and easy to do.23

Depending on the site of the tumour, bone or cartilagerom the dorsum or cartilage from the nasal tip has to beacrificed to increase the margin of safety. This may lead ton open roof deformity, which can be corrected by osteotomyf the nasal wall. Once the soft tissue cover of the nose haseen dissected to close the defect, the osteotomy can be madender direct vision, which is controllable and precise with aimited potential for complications such as damage to theurrounding soft tissue. It can be done with an appropriateurgical burr.22,24 Tip-forming techniques used in aesthetichinoplasty can also help to shape the nasal tip, reduce the sizef the defect, and achieve an adequate margin of safety.14,15

After the lateral nasal wall is in position, various localaps can be used to close the defect without leaving a visibleeformity. We have been using these procedures, includ-ng osteotomy and tip-forming techniques, as an importantdjunct to other techniques in reconstructive nasal surgery tomprove the result.

Because the osteotomies were made under direct vision,hey could be made exactly along the planned path. These of a diamond burr allows the required osteotomy toe made exactly and easily – lateral, median, or transversewithout damaging the nasal mucosa or causing a com-inuted fracture pattern. We encountered no irregularities

f the dorsum, the nasal wall did not collapse, and thereere no unwanted fractures, which can cause comminuted

ractures and spicules. The establishment of the normal sub-urface architecture of the nose is essential to improve theefinition of nasal landmarks, even if the missing anatomyas been precisely duplicated. An adequate local flap with

1

Maxillofacial Surgery 53 (2015) 44–48 47

ufficient mobilisation and narrowing of the hard-tissueeduces the tension and improves the accuracy of the inser-ion of the flap. A soft tissue envelope similar in appearanceo the surrounding skin creates the visual impression of nor-

ality. The patient’s preoperative fear of having a deformedgly nose could be changed to postoperative satisfaction, soe were able to help to relieve the problems of excision of a

ancer. Even the relatives were astonished.We conclude that the techniques of aesthetic rhinoplasty,

rom osteotomy of the nasal wall to formation of the tip, areseful refinements that can optimise the outcome of recons-ructive nasal surgery.

onflict of interest

e have no conflict of interest.

thics statement/confirmation of patient’s permission

he patient has given us permission to publish the pho-ographs.

We have no financial interest and we did not have anynancial or material support concerning this study.

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