Page 58 - Read Online

Page 4 of 14 Patel et al. Plast Aesthet Res 2024;11:20 https://dx.doi.org/10.20517/2347-9264.2024.17

is not routine, it should be considered for patients with significant craniofacial deformity or a history of
trauma.

TREATMENT OPTIONS
A number of techniques to address the nasal framework and lengthen the short nose have been
[3]
forwarded . The variability in patient goals and nasal anatomy prevents a one-size-fits-all approach. As
aforementioned, treatment requires an understanding of the pathology associated with the perceived nasal
deformity. However, in nearly all cases, there exists insufficient quantity or quality of competent nasal
osseocartilaginous structure. Therefore, fundamental to the correction of the short nose is the introduction
or replacement of cartilaginous support. While camouflaging and onlay techniques can give the appearance
of an elongated nose, relying solely on these methods without adequate underlying support will yield an
unfavorable long-term result.

INITIAL APPROACH
The initial approach to a short nose includes complete elevation and release of the nasal soft tissue and
ligaments off all bony and cartilaginous attachments. This step is necessary for adequate redraping of the
skin. It entails lifting the soft tissue off the entire bony vault (as is the case in most open piezotome-based
rhinoplasty procedures). In patients with thick skin or scar contracture, conservative thinning or excision of
the scar can be performed. The nasal SMAS can be thinned independent of the overlying subdermal fat.
While this can restore some skin elasticity and create a more uniform and compliant soft tissue envelope, it
is extremely crucial to minimize disruption to the subdermal vascular plexus as the skin will already be at
risk of necrosis when placed under tension . Release of any scar tissue between the upper lateral cartilages
[8]
and lateral crural remnants is imperative. This dissection is taken down to the level of the mucosa without
violation. This will allow downward movement of the vestibular mucosa with lateral crural repositioning
while maintaining a vascularized internal lining (avoid releasing cuts here).

MANAGEMENT OF THE NASAL SEPTUM
At the cornerstone of an appropriately sized nose is the stability and length of the nasal septum. In cases
where a shortened nose is due to iatrogenic or inflammatory causes, the septal cartilage is often
compromised. Therefore, while septal cartilage can have robust strength and is a preferred graft material in
many primary cases, alternative grafting sources are typically needed for most cases of short noses. Costal
cartilage is usually preferred because of its strength and the ability to harvest long, straight segments.
Although some authors tout the capabilities of homologous cartilage (i.e., cadaveric), particularly
fresh-frozen, we favor using autologous cartilage [9,10] . While the harvest of costal cartilage has been described
elsewhere, several elements are worth outlining. First, the 7th costal cartilage is preferred for harvest because
it enables the extraction of long cartilage segments with a theoretically lower risk of pneumothorax, as the
[11]
dissection occurs below the diaphragm . Sharp division of fascia but blunt separation of muscle fibers can
limit pain. Preservation and harvest of perichondrium can be considered for camouflaging purposes. Costal
cartilage grafts should be obliquely cut to minimize warping and subsequently left in saline for 30 min to
[12]
assess for inherent warping . These later points are particularly important when using longer cartilage
grafts [Figure 3].

Fundamental to lengthening and counter rotation of a short nose is a midline, stable base structure (i.e., a
strong native septum, a septal extension graft, or anterior septal reconstruction). The use of septal extension
grafts (SEG) provides the most powerful mechanism to elongate and project the nasal septum . Compared
[13]
to classic columella strut grafts, which are not fixed to the native septum, SEGs provide improved long-term
tip stability and position . A variety of techniques have been described in the design and placement of
[14]