2017-18 HSC Section 4 Green Book

Volume 139, Number 3 • Open Dorsal Approach to Rhinoplasty

and this allows placement of upper lateral cartilage tension-spanning sutures (and spreader grafts if needed) to restore the internal nasal valve and/or to straighten a deviated dorsal septum 7,8 or to recon- struct an open roof deformity. 9 Deviated Nose Nasal deviation can be the result of abnormal anatomy of any of the osseocartilaginous compo- nents of the nose, but always includes the septum. Before correction, accurate diagnosis of the respon- sible components must be performed as standard- ized by the senior author (R.J.R.) in his description of the aesthetic analysis of the nose. 10 Corrective maneuvers to address nasal deviation are nearly always targeted at the septum. The key to a straight nose is a straight septum and, often, if it is a high dor- sal deviation, it will require direct visualization and weakening and thus a spreader graft may be needed. This is routinely performed as part of the compo- nent dorsal hump reduction. 5 Nasal deviation can also be corrected with spreader grafts as mentioned previously. These maneuvers require wide exposure of the septum in the submucoperichondrial plane, which is achieved using the anterior septal angle as the first anatomical point of exposure. Functional Airway Obstruction Functional septal reconstruction is an essential component of the rhinoplasty for a patient with nasal airway obstruction caused by a deviated sep- tum. Dissection is begun at the anterior septal angle and directed posteriorly. Mucoperichondrial flaps are raised and the entire septum is exposed down to its osseocartilaginous junctions, caudally to the maxillary crest and posteriorly to the vomer. This maneuver releases extrinsic deforming forces attrib- utable to the surrounding cartilaginous framework and soft tissue and may correct the septal deviation. If the septum is deviated because of asymmetry of the vomer or maxillary crest, the septum can be frac- tured at its osseous junction and allowed to return to midline. In the case of intrinsic septal deviation, the deviated portion of the septum can be resected while taking care to maintain an adequate dorsal L-strut of at least 15 mm if possible. Cartilage Harvest The quadrangular cartilage is an excellent donor site for cartilage grafts and can be accessed in the same manner as described previously. Creation of an adequate L-strut is crucial to preventing nasal collapse. The anterior septal angle is the best way to approach the septum to fully and safely visualize Posterior

dissection can proceed with more certainty. The described dissection carefully separates the osseo- cartilaginous framework of the nose, providing exposure of all essential components for aesthetic modifications critical to obtaining a pleasing and reproducible result. Even in revision procedures, identification of the anterior septal angle allows predictable exposure, making aesthetic and func- tional modifications more feasible. Meticulous attention to detail during exposure of the anterior septal angle is essential to having a successful outcome in primary and secondary rhinoplasty. The four gateways describe why the anterior septal angle is so critical in ensuring and attaining great results in rhinoplasty. THE FOUR GATEWAYS: ROLE OF THE ANTERIOR SEPTAL ANGLE Dorsal Dorsal Aesthetic Line Creation/Restoration The dorsal aesthetic lines are constituted by the bony vault, upper lateral cartilages, and lower lateral cartilages, and end at the tip-defining points. Harmonious dorsal aesthetic lines rely entirely on the anatomical congruity of these components. 6 The anterior septal angle allows for assessment and visualization of the dorsal aes- thetic lines on the dorsum. Some key maneuvers for achieving ideal dor- sal aesthetic lines are component dorsal hump reduction, dorsal septal graft harvest for columel- lar struts and other grafts, and nasal bone reduc- tion. Most of these maneuvers require dissociation of the cartilaginous framework to achieve the cor- rect exposure for adequate cartilage resection and placement of grafts. This exposure hinges on the initial identification of the anterior septal angle to begin the submucoperichondrial flaps and release of the upper and lower lateral cartilages. Septal Reduction and Spreader Grafts Access to the dorsum allows a variety of maneu- vers such as dorsal hump reduction and placement of spreader grafts. The dorsal hump can be reduced using the reliable method described previously by the senior author (R.J.R.). 5 Spreader grafts have proven to have great versatility in rhinoplasty, and can be placed in different ways, depending on the indication. To widen the internal nasal valve, the dis- section begins just cephalad to the anterior septal angle in the submucoperichondrial plane between the upper lateral cartilages and the septum. Often, the upper lateral cartilages are separated from the septum, as in the case of dorsal septal reduction,

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