Comparison of Osteotomy Techniques in the Treatment of Nasal Fractures Craig S. Murakami, M.D., and Wayne E Larrabee, Jr., M.D.
of lateral osteotomy effectively narrowed the nose as Joseph had intended but unfortunately medialized the entire lateral aspect of the piriform aperture and reduced the nasal airway. During the 1920s, Joseph trained Aufricht, Safian, and Foman, who continued the widespread dissemination of Joseph's lateral saw osteotomy technique throughout America. This period also contained surgeons who advocated the use of nasal forceps and heavy bone scissors5 or developed cumbersome electric osteotomy saws.6-7 However, the predominant method continued to be Joseph's saw osteotomy technique. Although Weir had initially described the percutaneous chisel osteotomy technique in his first article, there were few early followers of the chisel technique. 89 However, by the late 1920s and throughout the 1930s, an increasing number of surgeons converted to using chisels,10-11 whereas others continued to condemn their usage12-13 on the assumption that chisels were imprecise and created more comminution of the bone. Problems with postoperative nasal airway obstruction secondary to overnarrowing of the lateral nasal walls became apparent14 and saw osteotomy techniques became suspect. Maurice Cottle observed problems with the standard Joseph osteotomy and devised his unique push-down operation to preserve the nasal airway.15 This technique involved lowering the nasal hump deformity with lateral osteotomies, reducing the nasal septum, and posterior
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To understand the various osteotomy techniques currently used, one must review the historical progression of lateral osteotomies. John Roe is usually credited with the first rhinoplasty publication in 1887. However, this particular rhinoplasty was the reduction of a pug nose deformity and did not require any bone work.1 It was an endonasal approach to reduce the excess soft tissue and cartilage of a bulbous tip. This report was quickly followed by that of Robert Weir's rhinoplasty in 1892.2 This report included two cases in which Weir addressed problems with the lateral nasal wall. For infracturing the lateral nasal walls, Weir used nasal forceps (with one blade on the inside of the nose and one blade on the outside) or a percutaneous chisel osteotomy 2 In 1898, Jacques Joseph reported the results of his initial rhinoplasty cases, and although he may not have been the first to describe the rhinoplasty operation, he was the first to truly master this operation and he developed osteotomy techniques that dominated rhinoplastic surgery for over half a century.3 He was intense, dedicated, creative, and an astute anatomist. He quickly designed specific rhinoplasty instruments and techniques that became the standard armamentarium of rhinoplasty surgeons. The standard lateral osteotomy he developed was accomplished with a Joseph saw placed under a subperiosteal tunnel.3 The osteotomy began at the inferior most aspect of the piriform aperture, extended low along the frontal process of the maxilla, and ended at or beyond the nasof rontal suture (Fig. I).3'4 This type
Department of Otolaryngology—Head & Neck Surgery, University of Washington, Seattle, Washington Reprint Requests: Dr. Murakami, University of Washington, Department of Otolaryngology— Head & Neck Surgery, Mail Stop: RI^30, Seattle, WA 98195 Copyright ©1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
209
g
SAW OSTEOTOMI
I
Figure 1. Joseph saw osteotomy.
repositioning of the intact bony-cartilaginous nasal dorsum. Cottle's osteotomies were performed with both the saw and chisels, using the saw to score the bone and a 7mm chisel to complete the osteotomy. If the lateral osteotomy extended below the inferior turbinate, the retrodisplaced nasal pyramid would impinge on the anterior aspect of the inferior turbinate. In cases requiring large hump reductions, bilateral intermediate osteotomies were performed and the lateral nasal wall between these two cuts removed. Not all surgeons were followers of Dr. Cottle and the majority of surgeons continued to use the more traditional low-low lateral osteotomy configuration,l6 but gradually converted to using chisels. Over time, surgeons elevated the inferior aspect of the lateral osteotomy to a point approximating the attachment
Figure 2.
210
of the inferior turbinate (Fig. 2). It was also observed that most patients required little or no narrowing around the nasal radix and that lateral osteotomies that extended past the convexity of the lateral radix resulted in a "rocker deformity."l7,18Therefore it was unnecessary to extend the osteotomy as superior or as low (close to the medial canthus) in the region of the nasal radix. Consequently chisel osteotomies gradually evolved into a low-high configuration that did not extend into the dense bone of the nasofrontal suture (Fig. 3).19-2* Webster et a125 and Farrior26 noted the importance of preserving the lateral nasal suspensory ligament attachments to the piriform aperture to prevent iatrogenic nasal obstruction. They advocated a curved lateral osteotomy design in a high-low-high configuration, which preserved this important triangle of maxillary bone (Fig. 4). As we entered the 1970s, surgeons chose the low-low, the low-high, or the high-low-high configurations according to their experience and training, sometimes irrespective of each patient's specific anatomy. In the 1980s, surgeons tailored their osteotomy techniques according to each individual patient's unique anatomy and also designed methods to reduce edema, bleeding, and nasal wall instability. A specialized osteotomy configuration is the double, or intermediate, lateral osteotomy in which a higher osteotomy is made parallel to what is usually a low-low lateral osteotomy (Fig. 5). Foman27 used this intermediate type of osteotomy to equalize crooked noses that appeared to have as part of their deformity a concave (long)lateral surface and a contralateral concave (short) surface. He recommended an intermediate osteotomy on the concave side and a standard osteotomy on the convex side. The redundant segment was then removed from the concave
Low-low osteotorny. Figure 3. Low-high osteotorny. (Arrows depict the change in osteotomy configuration.)
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FACIAL PLASTIC SURGERY Volume 8, Number 4 October 1992
COMPARISON OF OSTEOTOMY TECHNIQUES-Murakami,
k
PERFORATED OSTEOTOMY
'1.
!
\
I' f4.INTERMEDIATE OSTEOTOMY Figure 5. Intermediate osteotomy.
side and inlaid into the osteotomy site on the convex side; thus, equalizing both sides of the lateral nasal wall and centering the nasal dorsum. Others describe intermediate osteotomy techniques on the longer side of crooked noses without removing the excess bone.21J6,2&30 perforating osteotomies with a small 2 or 3 mm chisel represents another technique to perform latera1 osteotomies (Fig. 6). Chisels can be used either intranasally31,32 or percutaneously33 and the osteotomies are made in the various configurations previously described. Many believe the perforating techand reduced the nique preserved periosteal risk of lateral wall collapse. Additional techniques designed to minimize periosteal and mucosal trauma and improve nasal SUPport include intranasal osteotomies produced with
(
Figure 6- Perforated osteotom~.
a curved guarded chisel, which has the guard positioned along the internal surface of the bone34 and the micro-osteotomy technique using a 2 rnrn straight intranasal chisel.30 Other surgeons attempt to preserve the periosteal support by elevating subperiosteal tunnels over the nasomaxillary path of the lateral osteotomy (Fig. 7A-C). Advocates of tunnels also believe that they reduce the risk of periosteal bleeding and injury to the angular artery. Although subperiosteal tunnels have been described by multiple authors,3,26,31,35,36 an anatomic dissection and examination of the periosteum after different chisel techniques were applied was necessary to determine its efficacy. This experimental cadaver study was undertaken to examine the location and smoothness of the osteotomy site and determine the amount of damage to the periosteum and nasal mucosa caused by the following techniques: intermediate osteotomy, standard high-low-high osteotomy with and without a subperiosteal tunnel, and the percutaneous perforating osteotomy
MATERIALS AND METHOD Sixty fresh-frozen cadaver heads were obtained at the timeof death ranged from for dissection. 20 to 75 years with an equivalent number of female male specimens. ~ 1specimens 1 medial osteotomies in a vertical or oblique manner and then divided into three groups. G~~~~ I: 20 specimens underwent a right intermediate osteotomy followed by a high-low-high lateral osteotomy using either a curved 4 mm ~~i~~~~or a straight Parkes osteotome. On the left, specimens underwent low-high osteotomy with a straight 4 mm
,,,
.
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Figure4. High-low-high osteotomy. (* = preserved bone which attaches to the suspensory ligaments.)
Larrabee
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FACIAL PLASTIC SURGERY Volume 8, Number 4 October 1992
Figure 7.
A-C: Periosteal tunnels with periosteum in-
tact.
Neivert or Parkes chisel (Fig. 8). Group 11: 20 specimens underwent creation of a right subperiosteal tunnel with a Joseph or Mackenty elevator. A curved and straight 4 mm Neivert and a straight Parkes chisel were used to create a high-low-high (curved) lateral osteotomy On the left, identical osteotornies were created without periosteal elevation. Group 111: 20 specimens underwent a right high-low-high osteotomy with either a curved or straight 4 mm Neivert and a left percutaneous perforating osteotomy using
a 2 mm straight chisel (Fig. 9). After osteotomies were performed and the nasal wall infractured, the soft tissue was dissected and the periosteum, bony fragments, and nasal mucosa examined. RESULTS
Group I specimens were found to have complete disruption of the periosteum with both the Parkes or
J
1
/
l
Figure 8.
6
Group I, right intermediate, left low-high.
Larrabee
Neivert chisels; however, there was less disruption of underlying nasal mucosa with the Neivert chisels. The Neivert was used with the guard placed on the external surface of the bone and not internally, as the chisel was originally designed. Both chisels produced complete osteotomies without comminution and allowed adequate infracturing of the nasal walls. High-low-high lateral osteotomies produced a disruption of both the periosteum and the nasal mucosa in the majority of cases that was similar to the contralateral low-high osteotomy (Fig. 10). At the intermediate osteotomy site, the nasal mucosa appeared to remain partially intact and the osteotomy site created a hingelike weakness in the lateral nasal wall that tended to bend in a concave manner. Intermediate and lateral osteotomies were straight, clean, and without comminution (Fig. 11). Group I1 specimens, which underwent creation of a subperiosteal tunnel prior to osteotomy, were found to have preservation of the periosteum and overlying soft tissue in the majority of cases when the curved Neivert osteotome was used. There was more destruction of this layer if the straight Neivert of Parkes osteotome was used because of the lateral required the aspect of the osteotomy. Because of its greater size, the Parkes osteotome resulted in greater periosteal disruption. The subperiosteal tunnel did not appear to yield a dramatic difference in nasal wall support when compared with the contralateral high-lowhigh osteotomy without tunnels. Group I11 specimens, which underwent the percutaneous perforatingosteotomy technique, were found to have only partial disruption of the periosteum and minimal injury to the nasal mucosa. The osteotomy site was complete, irregular along its margin, and demonstrated small comminutions along the osteotomy (Fig. 12). It appeared to be equivalent to the high-low-high technique in narrowing the nose but seemed to provide increased stability to the infractured segment, since there was minimal mucosal or periosteal disruption. The percutaneous technique was simple to perform and consistent results were obtained.
\ 1
Y
\
I/
'I5
Figure 9. osteotomy.
Group Ill, right high-low-high, left perforating
DISCUSSION The specific osteotomy technique used to treat a given fracture patient depends on the surgical anatomy of the deformity. Nasal bones of uneven length require an intermediate osteotomy on the longer side to straighten the nose. Our approach to this deformity is seen in Figure 13. This young man with a long-standing nasal deformity resulting in the left nasal bone being longer than the right was treated
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COMPARISON OF OSTEOTOMY TECHNIQUES-Murakami,
--
Figure 10. Lateral osteotomy with disruption of periosteum.
-
--
--
Figure 12. Perforating osteotomy with microcomminutions and intact periosteum.
with an intermediate osteotomy on his left side or the longer nasal bone. The order of osteotomies in this case is quite important and should be performed similar to "opening a book." The intermediate osteotomy is always performed first because it cannot be done well once the lateral osteotomy has been made and the nasal bones are no longer stable. We would prefer to use a small 3 mm or 2 mm osteotome for this particular osteotomy The lateral osteotomy on the same side is then performed to help move that nasal base to the midline. A medial osteotomy is then performed on the same side to move the nasal bone on that side to the midline and to create a space to move the right nasal bone into position. Next, the medial osteotomy on the opposite side is performed, both to create a back-fracture site an3 to move the septum to the midline. Finally the lateral osteotomy on the side contralateral to the intermediate osteotomy is performed and the nasal bones are completely mobilized and moved toward the midline. One can use whichever lateral osteotomy technique is usual, and generally we prefer a modified Neivert osteotome in which the guard has been smoothed and the blade somewhat shortened. For nasal fractures that are essentially midline but where the nose has been widened and there are irregularities, a surgeon's standard rhinoplasty oste-
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FACLAL PLASTIC SURGERY Volume 8, Number 4 October 1992
Larrabee
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COMPARISON OF OSTEOTOMY TECHNIQUES-Murakami,
Figure 13. A sequential approach using intermediate osteotomies to straighten the asymmetrical deviated nose. A: Preoperative view with deviation to right. B: Operative view. C: Intermediate osteotomy is first made on the side of the longer nasal bone. D: A lateral osteotomy is then created on the same side. (Figure continued on next page)
otomy technique can be performed. The perforating technique in these cases has advantages in that the extra support allows the nose to be narrowed in a safer manner. Such a patient is seen in Figure 14. The actual choice of osteotome and osteotome
technique depends to a large degree on the surgeon's training experience. Ideally, a specific technique would be selected for a specific patient based on that patient's individual anatomy and needs. In general, thicker boned patients (the "gladiator nose") 215
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FACIAL PLASTIC SURGERY volume 8, Number 4 October 1992
Figure 13, cont. E: A medial osteotomy is then created on the same side to move the nasal bone to the midline and create a space for the opposing nasal bone. F: The contralateral medial osteotomy is then created to create a back-fracture site and to move the bony septum toward the midline. G: The contralateral lateral osteotomy i s then made to move the nasal bone to the midline and complete theosteotomy sequence. H: A perforatingosteotomy can be used as needed to mobilize the nasal bones to the midline. (Figure continued on next page)
COMPARISON OF OSTEOTOMY TECHNIQUES-Murakami,
Larrabee
Figure 13, cont. I: Osteotomies completed. J: A dorsal onlay cartilaginous graft can be used to camouflage any slight persistent deviation of the dorsal septum.
taneous osteotomy to create the back-fracture using a 2 mm chisel. We use the perforating technique quite commonly and have yet to see a scar or other problem result from it.
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require larger osteotomes. In our practice that means a modified Neivert. In more delicately boned individuals, osteotomies can be quite easily created with a 2 or 3 mm chisel using either a perforating or a straight-cut technique. With the 2 mm chisel, the perforating osteotomies can be made either percutaneously or intranasally. In the long traumatized nose with widened nasal bones it is usually necessary to mobilize the bones totally to get them straight and narrow. Whichever lateral osteotomy technique is performed, it is frequently necessary to do a percu-
SUMMARY The treatment of nasal fractures in a delayed manner poses special technical problems. One frequently must deal with both deviated nasal bones and with
Figure 14. A young woman undergoing delayed treatment of a nasal fracture. Because of her delicate skin and fragility of the nasal bones, the perforating osteotomy technique was used. A: Preoperative frontal view. 8: Postoperative frontal view. (Figure continued on next page)
217
Figure 14, cont.
C: Preoperative lateral view. D: Postoperative lateral view.
varying asymmetries of the nasal bones. The trauma itself and healing create a situation with which there is sometimes instability and in which there are preexisting fractures sites in locations different from the standard osteotomy positions. Lateral osteotomy techniques have been refined over the past century as a result of continuous study of the nasal anatomy, nasal airway, bone and soft tissue dynamics, and aesthetic norms. Surgeons are now able to choose the lateral osteotomy technique most appropriate for each patient and avoid the aesthetic and functional complications that occur when a single osteotomy technique is applied in all situations. Fresh cadaver dissection provided us with the opportunity to examine directly the osteotomies created by a few of these techniques and comment on our observations. All standard osteotomy techniques resulted in predictable osteotomy sites. The perforation technique resulted in a slightly more irregular osteotomy but one with better soft tissue support.
REFERENCES 1. Roe J: The deformity termed "Pug Nose" and its correction by a simple operation. Med Rec 31:621-623, 1887 2. Weir RF: O n restoring sunken noses without scarring the face. NY Med J 56:449-454, 1892 3. Joseph J: Die Hypertrophic der starren Nase. Nasenplastik und
sonstige gesichtsplastik nebsteinernanhang iiber srnarttrnaplastik und einige weitere Operationen aus dent gebiete der ausseren Korperplastik. Leipzig: Kabitzsch, 1931 Aufricht G: Joseph's rhinoplasty with some modifications. Surg Clin North Am 51:229-316, 1971 Tieck GJE: New intranasal procedures for the correction of deformities of the nose, successfully applied in over 1,000 cases during the past twelve years. Am J Surg 34:117-120, 1920 Roe JO: An electric nasal saw. NY Med J 47:120-121, 1888 Seltzer AP: The Seltzer circular rhinoplastic saw. Plast Reconstr Surg 5:261-263, 1949 Mosher HP: The direct method of correcting the lateral deformity of the nasal bones. Laryngoscope 16:28-33, 1906 Roberts JB: The cosmetic surgery of the nose. JAMA 19:231233, 1892 Metzenbaum M: Nasal reconstruction by means of the bone and cartilage existing within the old traumatized nose. Laryngoscope 40:488-494, 1930 Sheehan JE: Correction of nasal disfigurements by readjustment of the framework and tissues. Arch Otolaryngol 10: 584-596, 1930 Cinelli J: Correction of nasal deformities. NY State J Med 37:1018-124, 1937 Maliniak JW: Correction of facial deformities with special reference to rhinoplasty Eye Ear Nose Throat Monthly 9: 1930 Palmer A: Complications following rhinoplasty. Arch Otolaryngol 38:538-545, 1938 Cottle M: Corrective Surgery: Nasal Septum and External Pyramid-Study Notes and Laboratory Manual. Chicago: American Rhinologic Society 1960 Becker OJ: Plastic Surgery of the Nose. Principles of Otolaryngologic Plastic Surgery. American Academy of Ophthalmology and Otolaryngology 1958 Wright WK: General principles of lateral osteotomy and hump removal. Tr Am Acad Ophth Otol 65:854-861, 1961 Wright W: Lateral osteotomy in rhinoplasty. Arch Otolaryngol 78:680-685, 1963
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FACIAL PLASTIC SURGERY Volume 8, Number 4 October 1992
COMPARISON OF OSTEOTOMY TECHNIQUES-Murakami,
Tardy ME, et al: Micro-osteotomy in rhinoplasty. Facial Plast Surg 1:137-145, 1984 Rees TD: Aesthetic Plastic Surgery. Philadelphia: WB Saunders, 1980 Diamond HP: Rhinoplasty technique. Surg Clin North Am 51:317-331, 1971 Bull T: Personal communication, 1988 Hilger JA:The internal lateral osteotomy in rhinoplasty Arch Otolaryngol 88:119-120, 1968 Daniel RK, Ethier R: Rhinoplasty: ACT scan analysis. Plast Reconstr Surg :174-182, 1987 Thomas JR, et al: Steps for a safer method of osteotomies in rhinoplasty. Laryngoscope 97:746-747, 1987 Ford CN, et al: Preservation of periosteal attachment in lateral osteotomy Ann Plast Surg 13:107, 1984
Special thanks to Drs. Pat Barelli, Glenn Drumheller, Morey Parks, William Silver, Carl Sputh, and Joseph West for their comments and suggestions. Also thanks to Dr. Edward Ricciadelli for his laboratory assistance.
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Anderson JR: A new approach to rhinoplasty Tr Am Acad Opthal Otol 70:183-192, 1966 Anderson JR: A personal technique of rhinoplasty. Oto Clin North Am 8:559-562, 1975 Anderson JR, Ries WR: Rhinoplasty: Emphasizing the External Approach. New York: Thieme, 1987 Sheen JH: Aesthetic Rhinoplasty. St Louis: C. V. Mosby, 1978 Cottle M: Rhinology-the collective writing of Maurice H . Cottle. Barelli PA, et a1 (eds). American Rhinologic Society, 1987 Daniel RK, Lessard ML: Rhinoplasty: A graded aestheticanatomical approach. Ann Plast Surg 13:436-451, 1984 Webster RC, et al: Curved lateral osteotomy for airway protection in rhinoplasty. Arch Otolaryngol 103:454-458, 1977 Farrior RT: The osteotomy in rhinoplasty. Laryngoscope 88: 1449-1459, 1978 Foman S: Surgery of Injury and Plastic Repair. Baltimore: Williams & Wilkins, 1939 Parkes ML, et al: Double lateral osteotomy in rhinoplasty Arch Otolaryngol 103:344-348, 1977 Bridger GP: Multiple osteotomies in rhinoplasty Aust NZ J Surg 4:363-366, 1981
Larrabee
of lateral osteotomy effectively narrowed the nose as Joseph had intended but unfortunately medialized the entire lateral aspect of the piriform aperture and reduced the nasal airway. During the 1920s, Joseph trained Aufricht, Safian, and Foman, who continued the widespread dissemination of Joseph's lateral saw osteotomy technique throughout America. This period also contained surgeons who advocated the use of nasal forceps and heavy bone scissors5 or developed cumbersome electric osteotomy saws.6-7 However, the predominant method continued to be Joseph's saw osteotomy technique. Although Weir had initially described the percutaneous chisel osteotomy technique in his first article, there were few early followers of the chisel technique. 89 However, by the late 1920s and throughout the 1930s, an increasing number of surgeons converted to using chisels,10-11 whereas others continued to condemn their usage12-13 on the assumption that chisels were imprecise and created more comminution of the bone. Problems with postoperative nasal airway obstruction secondary to overnarrowing of the lateral nasal walls became apparent14 and saw osteotomy techniques became suspect. Maurice Cottle observed problems with the standard Joseph osteotomy and devised his unique push-down operation to preserve the nasal airway.15 This technique involved lowering the nasal hump deformity with lateral osteotomies, reducing the nasal septum, and posterior
Downloaded by: Universite Laval. Copyrighted material.
To understand the various osteotomy techniques currently used, one must review the historical progression of lateral osteotomies. John Roe is usually credited with the first rhinoplasty publication in 1887. However, this particular rhinoplasty was the reduction of a pug nose deformity and did not require any bone work.1 It was an endonasal approach to reduce the excess soft tissue and cartilage of a bulbous tip. This report was quickly followed by that of Robert Weir's rhinoplasty in 1892.2 This report included two cases in which Weir addressed problems with the lateral nasal wall. For infracturing the lateral nasal walls, Weir used nasal forceps (with one blade on the inside of the nose and one blade on the outside) or a percutaneous chisel osteotomy 2 In 1898, Jacques Joseph reported the results of his initial rhinoplasty cases, and although he may not have been the first to describe the rhinoplasty operation, he was the first to truly master this operation and he developed osteotomy techniques that dominated rhinoplastic surgery for over half a century.3 He was intense, dedicated, creative, and an astute anatomist. He quickly designed specific rhinoplasty instruments and techniques that became the standard armamentarium of rhinoplasty surgeons. The standard lateral osteotomy he developed was accomplished with a Joseph saw placed under a subperiosteal tunnel.3 The osteotomy began at the inferior most aspect of the piriform aperture, extended low along the frontal process of the maxilla, and ended at or beyond the nasof rontal suture (Fig. I).3'4 This type
Department of Otolaryngology—Head & Neck Surgery, University of Washington, Seattle, Washington Reprint Requests: Dr. Murakami, University of Washington, Department of Otolaryngology— Head & Neck Surgery, Mail Stop: RI^30, Seattle, WA 98195 Copyright ©1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
209
g
SAW OSTEOTOMI
I
Figure 1. Joseph saw osteotomy.
repositioning of the intact bony-cartilaginous nasal dorsum. Cottle's osteotomies were performed with both the saw and chisels, using the saw to score the bone and a 7mm chisel to complete the osteotomy. If the lateral osteotomy extended below the inferior turbinate, the retrodisplaced nasal pyramid would impinge on the anterior aspect of the inferior turbinate. In cases requiring large hump reductions, bilateral intermediate osteotomies were performed and the lateral nasal wall between these two cuts removed. Not all surgeons were followers of Dr. Cottle and the majority of surgeons continued to use the more traditional low-low lateral osteotomy configuration,l6 but gradually converted to using chisels. Over time, surgeons elevated the inferior aspect of the lateral osteotomy to a point approximating the attachment
Figure 2.
210
of the inferior turbinate (Fig. 2). It was also observed that most patients required little or no narrowing around the nasal radix and that lateral osteotomies that extended past the convexity of the lateral radix resulted in a "rocker deformity."l7,18Therefore it was unnecessary to extend the osteotomy as superior or as low (close to the medial canthus) in the region of the nasal radix. Consequently chisel osteotomies gradually evolved into a low-high configuration that did not extend into the dense bone of the nasofrontal suture (Fig. 3).19-2* Webster et a125 and Farrior26 noted the importance of preserving the lateral nasal suspensory ligament attachments to the piriform aperture to prevent iatrogenic nasal obstruction. They advocated a curved lateral osteotomy design in a high-low-high configuration, which preserved this important triangle of maxillary bone (Fig. 4). As we entered the 1970s, surgeons chose the low-low, the low-high, or the high-low-high configurations according to their experience and training, sometimes irrespective of each patient's specific anatomy. In the 1980s, surgeons tailored their osteotomy techniques according to each individual patient's unique anatomy and also designed methods to reduce edema, bleeding, and nasal wall instability. A specialized osteotomy configuration is the double, or intermediate, lateral osteotomy in which a higher osteotomy is made parallel to what is usually a low-low lateral osteotomy (Fig. 5). Foman27 used this intermediate type of osteotomy to equalize crooked noses that appeared to have as part of their deformity a concave (long)lateral surface and a contralateral concave (short) surface. He recommended an intermediate osteotomy on the concave side and a standard osteotomy on the convex side. The redundant segment was then removed from the concave
Low-low osteotorny. Figure 3. Low-high osteotorny. (Arrows depict the change in osteotomy configuration.)
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FACIAL PLASTIC SURGERY Volume 8, Number 4 October 1992
COMPARISON OF OSTEOTOMY TECHNIQUES-Murakami,
k
PERFORATED OSTEOTOMY
'1.
!
\
I' f4.INTERMEDIATE OSTEOTOMY Figure 5. Intermediate osteotomy.
side and inlaid into the osteotomy site on the convex side; thus, equalizing both sides of the lateral nasal wall and centering the nasal dorsum. Others describe intermediate osteotomy techniques on the longer side of crooked noses without removing the excess bone.21J6,2&30 perforating osteotomies with a small 2 or 3 mm chisel represents another technique to perform latera1 osteotomies (Fig. 6). Chisels can be used either intranasally31,32 or percutaneously33 and the osteotomies are made in the various configurations previously described. Many believe the perforating techand reduced the nique preserved periosteal risk of lateral wall collapse. Additional techniques designed to minimize periosteal and mucosal trauma and improve nasal SUPport include intranasal osteotomies produced with
(
Figure 6- Perforated osteotom~.
a curved guarded chisel, which has the guard positioned along the internal surface of the bone34 and the micro-osteotomy technique using a 2 rnrn straight intranasal chisel.30 Other surgeons attempt to preserve the periosteal support by elevating subperiosteal tunnels over the nasomaxillary path of the lateral osteotomy (Fig. 7A-C). Advocates of tunnels also believe that they reduce the risk of periosteal bleeding and injury to the angular artery. Although subperiosteal tunnels have been described by multiple authors,3,26,31,35,36 an anatomic dissection and examination of the periosteum after different chisel techniques were applied was necessary to determine its efficacy. This experimental cadaver study was undertaken to examine the location and smoothness of the osteotomy site and determine the amount of damage to the periosteum and nasal mucosa caused by the following techniques: intermediate osteotomy, standard high-low-high osteotomy with and without a subperiosteal tunnel, and the percutaneous perforating osteotomy
MATERIALS AND METHOD Sixty fresh-frozen cadaver heads were obtained at the timeof death ranged from for dissection. 20 to 75 years with an equivalent number of female male specimens. ~ 1specimens 1 medial osteotomies in a vertical or oblique manner and then divided into three groups. G~~~~ I: 20 specimens underwent a right intermediate osteotomy followed by a high-low-high lateral osteotomy using either a curved 4 mm ~~i~~~~or a straight Parkes osteotome. On the left, specimens underwent low-high osteotomy with a straight 4 mm
,,,
.
Downloaded by: Universite Laval. Copyrighted material.
Figure4. High-low-high osteotomy. (* = preserved bone which attaches to the suspensory ligaments.)
Larrabee
Downloaded by: Universite Laval. Copyrighted material.
FACIAL PLASTIC SURGERY Volume 8, Number 4 October 1992
Figure 7.
A-C: Periosteal tunnels with periosteum in-
tact.
Neivert or Parkes chisel (Fig. 8). Group 11: 20 specimens underwent creation of a right subperiosteal tunnel with a Joseph or Mackenty elevator. A curved and straight 4 mm Neivert and a straight Parkes chisel were used to create a high-low-high (curved) lateral osteotomy On the left, identical osteotornies were created without periosteal elevation. Group 111: 20 specimens underwent a right high-low-high osteotomy with either a curved or straight 4 mm Neivert and a left percutaneous perforating osteotomy using
a 2 mm straight chisel (Fig. 9). After osteotomies were performed and the nasal wall infractured, the soft tissue was dissected and the periosteum, bony fragments, and nasal mucosa examined. RESULTS
Group I specimens were found to have complete disruption of the periosteum with both the Parkes or
J
1
/
l
Figure 8.
6
Group I, right intermediate, left low-high.
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Neivert chisels; however, there was less disruption of underlying nasal mucosa with the Neivert chisels. The Neivert was used with the guard placed on the external surface of the bone and not internally, as the chisel was originally designed. Both chisels produced complete osteotomies without comminution and allowed adequate infracturing of the nasal walls. High-low-high lateral osteotomies produced a disruption of both the periosteum and the nasal mucosa in the majority of cases that was similar to the contralateral low-high osteotomy (Fig. 10). At the intermediate osteotomy site, the nasal mucosa appeared to remain partially intact and the osteotomy site created a hingelike weakness in the lateral nasal wall that tended to bend in a concave manner. Intermediate and lateral osteotomies were straight, clean, and without comminution (Fig. 11). Group I1 specimens, which underwent creation of a subperiosteal tunnel prior to osteotomy, were found to have preservation of the periosteum and overlying soft tissue in the majority of cases when the curved Neivert osteotome was used. There was more destruction of this layer if the straight Neivert of Parkes osteotome was used because of the lateral required the aspect of the osteotomy. Because of its greater size, the Parkes osteotome resulted in greater periosteal disruption. The subperiosteal tunnel did not appear to yield a dramatic difference in nasal wall support when compared with the contralateral high-lowhigh osteotomy without tunnels. Group I11 specimens, which underwent the percutaneous perforatingosteotomy technique, were found to have only partial disruption of the periosteum and minimal injury to the nasal mucosa. The osteotomy site was complete, irregular along its margin, and demonstrated small comminutions along the osteotomy (Fig. 12). It appeared to be equivalent to the high-low-high technique in narrowing the nose but seemed to provide increased stability to the infractured segment, since there was minimal mucosal or periosteal disruption. The percutaneous technique was simple to perform and consistent results were obtained.
\ 1
Y
\
I/
'I5
Figure 9. osteotomy.
Group Ill, right high-low-high, left perforating
DISCUSSION The specific osteotomy technique used to treat a given fracture patient depends on the surgical anatomy of the deformity. Nasal bones of uneven length require an intermediate osteotomy on the longer side to straighten the nose. Our approach to this deformity is seen in Figure 13. This young man with a long-standing nasal deformity resulting in the left nasal bone being longer than the right was treated
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Figure 10. Lateral osteotomy with disruption of periosteum.
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Figure 12. Perforating osteotomy with microcomminutions and intact periosteum.
with an intermediate osteotomy on his left side or the longer nasal bone. The order of osteotomies in this case is quite important and should be performed similar to "opening a book." The intermediate osteotomy is always performed first because it cannot be done well once the lateral osteotomy has been made and the nasal bones are no longer stable. We would prefer to use a small 3 mm or 2 mm osteotome for this particular osteotomy The lateral osteotomy on the same side is then performed to help move that nasal base to the midline. A medial osteotomy is then performed on the same side to move the nasal bone on that side to the midline and to create a space to move the right nasal bone into position. Next, the medial osteotomy on the opposite side is performed, both to create a back-fracture site an3 to move the septum to the midline. Finally the lateral osteotomy on the side contralateral to the intermediate osteotomy is performed and the nasal bones are completely mobilized and moved toward the midline. One can use whichever lateral osteotomy technique is usual, and generally we prefer a modified Neivert osteotome in which the guard has been smoothed and the blade somewhat shortened. For nasal fractures that are essentially midline but where the nose has been widened and there are irregularities, a surgeon's standard rhinoplasty oste-
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Figure 13. A sequential approach using intermediate osteotomies to straighten the asymmetrical deviated nose. A: Preoperative view with deviation to right. B: Operative view. C: Intermediate osteotomy is first made on the side of the longer nasal bone. D: A lateral osteotomy is then created on the same side. (Figure continued on next page)
otomy technique can be performed. The perforating technique in these cases has advantages in that the extra support allows the nose to be narrowed in a safer manner. Such a patient is seen in Figure 14. The actual choice of osteotome and osteotome
technique depends to a large degree on the surgeon's training experience. Ideally, a specific technique would be selected for a specific patient based on that patient's individual anatomy and needs. In general, thicker boned patients (the "gladiator nose") 215
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Figure 13, cont. E: A medial osteotomy is then created on the same side to move the nasal bone to the midline and create a space for the opposing nasal bone. F: The contralateral medial osteotomy is then created to create a back-fracture site and to move the bony septum toward the midline. G: The contralateral lateral osteotomy i s then made to move the nasal bone to the midline and complete theosteotomy sequence. H: A perforatingosteotomy can be used as needed to mobilize the nasal bones to the midline. (Figure continued on next page)
COMPARISON OF OSTEOTOMY TECHNIQUES-Murakami,
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Figure 13, cont. I: Osteotomies completed. J: A dorsal onlay cartilaginous graft can be used to camouflage any slight persistent deviation of the dorsal septum.
taneous osteotomy to create the back-fracture using a 2 mm chisel. We use the perforating technique quite commonly and have yet to see a scar or other problem result from it.
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require larger osteotomes. In our practice that means a modified Neivert. In more delicately boned individuals, osteotomies can be quite easily created with a 2 or 3 mm chisel using either a perforating or a straight-cut technique. With the 2 mm chisel, the perforating osteotomies can be made either percutaneously or intranasally. In the long traumatized nose with widened nasal bones it is usually necessary to mobilize the bones totally to get them straight and narrow. Whichever lateral osteotomy technique is performed, it is frequently necessary to do a percu-
SUMMARY The treatment of nasal fractures in a delayed manner poses special technical problems. One frequently must deal with both deviated nasal bones and with
Figure 14. A young woman undergoing delayed treatment of a nasal fracture. Because of her delicate skin and fragility of the nasal bones, the perforating osteotomy technique was used. A: Preoperative frontal view. 8: Postoperative frontal view. (Figure continued on next page)
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Figure 14, cont.
C: Preoperative lateral view. D: Postoperative lateral view.
varying asymmetries of the nasal bones. The trauma itself and healing create a situation with which there is sometimes instability and in which there are preexisting fractures sites in locations different from the standard osteotomy positions. Lateral osteotomy techniques have been refined over the past century as a result of continuous study of the nasal anatomy, nasal airway, bone and soft tissue dynamics, and aesthetic norms. Surgeons are now able to choose the lateral osteotomy technique most appropriate for each patient and avoid the aesthetic and functional complications that occur when a single osteotomy technique is applied in all situations. Fresh cadaver dissection provided us with the opportunity to examine directly the osteotomies created by a few of these techniques and comment on our observations. All standard osteotomy techniques resulted in predictable osteotomy sites. The perforation technique resulted in a slightly more irregular osteotomy but one with better soft tissue support.
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sonstige gesichtsplastik nebsteinernanhang iiber srnarttrnaplastik und einige weitere Operationen aus dent gebiete der ausseren Korperplastik. Leipzig: Kabitzsch, 1931 Aufricht G: Joseph's rhinoplasty with some modifications. Surg Clin North Am 51:229-316, 1971 Tieck GJE: New intranasal procedures for the correction of deformities of the nose, successfully applied in over 1,000 cases during the past twelve years. Am J Surg 34:117-120, 1920 Roe JO: An electric nasal saw. NY Med J 47:120-121, 1888 Seltzer AP: The Seltzer circular rhinoplastic saw. Plast Reconstr Surg 5:261-263, 1949 Mosher HP: The direct method of correcting the lateral deformity of the nasal bones. Laryngoscope 16:28-33, 1906 Roberts JB: The cosmetic surgery of the nose. JAMA 19:231233, 1892 Metzenbaum M: Nasal reconstruction by means of the bone and cartilage existing within the old traumatized nose. Laryngoscope 40:488-494, 1930 Sheehan JE: Correction of nasal disfigurements by readjustment of the framework and tissues. Arch Otolaryngol 10: 584-596, 1930 Cinelli J: Correction of nasal deformities. NY State J Med 37:1018-124, 1937 Maliniak JW: Correction of facial deformities with special reference to rhinoplasty Eye Ear Nose Throat Monthly 9: 1930 Palmer A: Complications following rhinoplasty. Arch Otolaryngol 38:538-545, 1938 Cottle M: Corrective Surgery: Nasal Septum and External Pyramid-Study Notes and Laboratory Manual. Chicago: American Rhinologic Society 1960 Becker OJ: Plastic Surgery of the Nose. Principles of Otolaryngologic Plastic Surgery. American Academy of Ophthalmology and Otolaryngology 1958 Wright WK: General principles of lateral osteotomy and hump removal. Tr Am Acad Ophth Otol 65:854-861, 1961 Wright W: Lateral osteotomy in rhinoplasty. Arch Otolaryngol 78:680-685, 1963
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Tardy ME, et al: Micro-osteotomy in rhinoplasty. Facial Plast Surg 1:137-145, 1984 Rees TD: Aesthetic Plastic Surgery. Philadelphia: WB Saunders, 1980 Diamond HP: Rhinoplasty technique. Surg Clin North Am 51:317-331, 1971 Bull T: Personal communication, 1988 Hilger JA:The internal lateral osteotomy in rhinoplasty Arch Otolaryngol 88:119-120, 1968 Daniel RK, Ethier R: Rhinoplasty: ACT scan analysis. Plast Reconstr Surg :174-182, 1987 Thomas JR, et al: Steps for a safer method of osteotomies in rhinoplasty. Laryngoscope 97:746-747, 1987 Ford CN, et al: Preservation of periosteal attachment in lateral osteotomy Ann Plast Surg 13:107, 1984
Special thanks to Drs. Pat Barelli, Glenn Drumheller, Morey Parks, William Silver, Carl Sputh, and Joseph West for their comments and suggestions. Also thanks to Dr. Edward Ricciadelli for his laboratory assistance.
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Anderson JR: A new approach to rhinoplasty Tr Am Acad Opthal Otol 70:183-192, 1966 Anderson JR: A personal technique of rhinoplasty. Oto Clin North Am 8:559-562, 1975 Anderson JR, Ries WR: Rhinoplasty: Emphasizing the External Approach. New York: Thieme, 1987 Sheen JH: Aesthetic Rhinoplasty. St Louis: C. V. Mosby, 1978 Cottle M: Rhinology-the collective writing of Maurice H . Cottle. Barelli PA, et a1 (eds). American Rhinologic Society, 1987 Daniel RK, Lessard ML: Rhinoplasty: A graded aestheticanatomical approach. Ann Plast Surg 13:436-451, 1984 Webster RC, et al: Curved lateral osteotomy for airway protection in rhinoplasty. Arch Otolaryngol 103:454-458, 1977 Farrior RT: The osteotomy in rhinoplasty. Laryngoscope 88: 1449-1459, 1978 Foman S: Surgery of Injury and Plastic Repair. Baltimore: Williams & Wilkins, 1939 Parkes ML, et al: Double lateral osteotomy in rhinoplasty Arch Otolaryngol 103:344-348, 1977 Bridger GP: Multiple osteotomies in rhinoplasty Aust NZ J Surg 4:363-366, 1981
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