Keywords rhinoplasty - prospective studies - measurements
Introduction
Jack Gunter in his classic book Dallas Rhinoplasty: Nasal Surgery by the Masters mentions that the access incisions in rhinoplasty should not be seen only as external
or internal accesses.[1 ] Every nasal access necessarily acts in specific areas of the nose with higher or
lower trauma, exposition, possibility of complex surgical maneuvers, and use of grafts
and/or sutures.
Several surgical maneuvers currently known in open rhinoplasty can be performed in
closed rhinoplasty, which results in less morbidity, reduced surgery time, and predictable
results. The knowledge and analysis of surgical techniques as well as the anthropometric
measurements of the nose make possible the quantitative analysis of the results, which
is of great importance for the surgeon and for the services regarding facial plastic
surgery. The record of surgical techniques performed is important for the study of
successes and the side effects of rhinoplasty.
High-quality clinical trials are essential for continuous scientific development.
They allow safe access to new information resulting in improvement of knowledge, target
planning, spread of evaluation of procedures, and professional conduct.
The Electronic System Integrated of Protocols (SINPE) is a computer program created
for manage database, idealized in the beginning of the 1990s by Dr. Osvaldo Malafaia,
whose purpose is the development of electronic protocols for fact gathering for its
subsequent utilization in clinical study.
In addition to enabling the construction of protocols, SINPE also provides a data
analysis module, which performs the descriptive statistical evaluation. This information
visualization interface, called SINPE Analyzer, is able to generate graphs and statistics,
save results, and export data.[2 ]
The present study aims to evaluate the main techniques used in rhinoplasty on Caucasian
noses, comparing preoperative and postoperative anthropometric measurements of the
nose.
Methods
This research was conducted in a private hospital. The work was approved by the ethics
committee of the institution (2528.135/20116), and an explained and free consent form
was provided to the patients.
Data collection was performed prospectively from February 2010 to March 2011 by the
researchers, using the SINPE software. A specific protocol called Rhinoplasty was
created based on 954 items, being part of the SINPE Analyzer module, which quickly
gathers the information in the protocols given by the data collection.[3 ]
[4 ] The generation and storage of graphs make possible a quick analysis of extensive
protocols, and it is also possible to copy each graph to the analysis sheet and include
comments and references, creating a sequence of self-analysis. This protocol was developed
by Dr. Cezar Berger in 2011 for his master's thesis.[5 ]
The SINPE Analyzer and statistical analysis (Student t test) were used for the validation of the protocol through the analysis of the existing
data in the database; p < 0.05 was considered significant.
The research started with 170 patients who underwent surgery; 58 patients, however,
were not present throughout the times evaluated, which makes 112 the total number
of patients who participated in all the phases of the study.
The information was collected in four phases: (D1) immediately postoperative and at
(D2) 3-month, (D3) 6-month, and (D4) 12-month follow-up. Patients' clinical conditions
were followed according to the specific need of each case. For the purpose of this
research, however, only the cases with 3, 6, and 12 months' postoperative follow-up
were taken into account.
The data evaluated corresponded to the primary rhinoplasties of the researcher. The
surgical techniques performed on the nasal tip, on the nasal dorsum, and on the nasal
base as well as the D1, D2, D3, and D4 records were evaluated. Preoperative and follow-up
photos at 12 months (D4) were analyzed objectively, and the measurements were compared
with the ideal aesthetic standard of a Caucasian nose. All the photos were taken by
the same researcher with the same camera and standardization: model Sony Cyber shot
DSCW125 7.2 Megapixels, 6.0 (Sony, Japan) fixed zoom at a distance of 1.5 m between
the camera and the volunteer to provide uniformity for the purpose of scale and measurements.
The positions were anteroposterior and direct profile.
Inclusion criteria were primary rhinoplasties, Caucasian noses, and age from 15 to
55 years. Exclusion criteria were previous surgical interventions on the nose and
on the face, non-Caucasian noses (Mestizo, Asian, Negroid), and patients who did not
return for follow-up.
The quantitative evaluation of the anthropometric measurements of the nose was performed
by comparing preoperative and 12-month follow-up (D4) photos. The following measurements
were analyzed and compared with the ideal aesthetic standard[6 ]
[7 ]: front view (anteroposterior; [Fig. 1 ]): (1) intercanthal distance, (2) interalar distance; side view (direct profile;
[Fig. 2 ]): (3) nasolabial angle, (4) nasal tip projection (through Goode's method; [Fig. 3 ]), and (5) nasofrontal angle.
Fig. 1 Front view (anteroposterior). 1, Intercanthal distance; 2, interalar distance.
Fig. 2 Side view (direct profile). Abbreviations: ANF, nasofrontal angle; ANL, nasolabial
angle.
Fig. 3 Side view (direct profile). Note: Measurement of the nasal tip projection through
Goode's method, which entails measurement of the perpendicular line from the tip point
(1) to the line of the facial plane (2) divided by the measurement of the line from
the nasion to the tip point.
According to the nature of the analyzed data, Student t test and the standard deviation test were applied. The level of significance adopted
was p < 0.05.
Results
Main Techniques Used in Rhinoplasty
Access (Approach)
The predominant access to the nose was endonasal (94.4%). The closed access without
inferior lateral cartilage exposure was predominant in 92.63% of cases against 7.37%
with delivery.
Surgical Techniques on the Nasal Dorsum
Removal of osteocartilaginous hump was the most frequent surgical technique performed
on the nasal dorsum (33.33%). Removal of the nasal hump did not happen in all the
cases. Release of the superior lateral cartilage was not systematically performed.
It was necessary to use grafts in some noses, which featured a change in the type
of nose to be operated—in other words, not all the noses needed a reduction operation
([Fig. 4 ]). Of the grafts, 41.94% of cases had camouflage type added (onlay graft), followed
by the spreader graft, which was used in 35.48% of cases ([Fig. 5 ]). In 60.67% of cases, a lateral osteotomy was performed, followed by paramedian
osteotomy in 15.33% of cases ([Fig. 6 ]). Cartilage was the most frequent graft donor site, with 90.32% of cases ([Fig. 7 ]); among them, the septal graft showed the highest frequency at 82.14% ([Fig. 8 ]).
Fig. 4 Surgical maneuvers on the nasal dorsum.
Fig. 5 Surgical maneuvers on the nasal dorsum—grafts.
Fig. 6 Surgical maneuvers on the nasal dorsum—osteotomies.
Fig. 7 Surgical maneuvers on the nasal dorsum—graft donor site.
Fig. 8 Surgical maneuvers on the nasal dorsum—graft donor site cartilage.
Surgical Techniques on the Nasal Tip
The use of sutures on the tip (24.76%) for definition and refinement was the most
frequent, followed by La Garde maneuver (19.44%) for detachment and adjustment of
the skin; then the resection of the membranous septum (15.67%) for cephalic rotation,
the placement of grafts (10.66%) for structure and refinement, and then the interposing
maneuver between the septum and the medial crura (tongue-in-groove; 9.72%) for support
of the tip. Cephalic resection of the inferior lateral cartilage occurred in only
5.02% of cases.
Resection of the membranous septum (15.67%) was twice as frequent as caudal septum
shortening (6.27%), which confirmed the lesser need of cartilaginous removal from
the tip of the noses ([Fig. 9 ]).
Fig. 9 Surgical maneuvers on the tip of the nose.
The lateral intercrural was the most frequent suture on the nasal tip, used in 32.39%
of cases. Next was the septocolumellar suture at 25.1% ([Figs. 10 ] and [11 ]). The highest frequency of the basal septocolumellar suture (low) was 58.51%, followed
by the rotation septocolumellar suture (high), which was observed in 41.49% of cases.
Fig. 10 Surgical maneuvers on the tip of the nose—sutures.
Fig. 11 Surgical maneuvers on the tip of the nose—medial intercrural suture.
The type of suture thread used in the surgical technique on the nasal tip is shown
in [Fig. 12 ], with the polydioxanone suture 4–0 being used in the majority of cases (70%).
Fig. 12 Surgical maneuvers on the tip of the nose—threads.
The columellar strut was the most frequent graft added to the nasal tip (56.86%),
with the cartilage of the nasal septum the most often used (81.08%).
Cephalic resection of the inferior lateral cartilage was predominantly performed through
McIndoe eversion technique or retrograde (70%).
Surgical Techniques on the Nasal Base
The three areas to be observed in the operation of the nasal base are: (1) the nostrils
(nasal vestibule), (2) the distance from the nasal base in relation to the intercanthal
distance, and (3) the alar-flare, in other words, the external outline of the lateral
wall of the inferior lateral cartilage right above the facial groove.
More than one technique can be performed on the same patient depending on the alterations
found. The most common techniques used were the correction of asymmetric nostrils
(28.38%), followed by cerclage (25.68%) to reduce the alar flare, and resection of
the alar base (22.97%) to reduce the width of the nasal base. For the internal correction
of the flaring of the lateral inferior wall, the technique of Cinelli was used in
10.81% of cases. Release of the periosteum from the premaxilla (1.35%) and alar wall
debulking (1.35%) were performed in only one patient. It was not necessary to perform
larger operations such as the V-Y advancement (0%) in any of the patients. There was
no incidence of dermabrasion, a procedure to reduce scars ([Fig. 13 ]).
Fig. 13 Surgical maneuvers on the nasal base.
The modified Weir's technique for the resection of the alar base was the most frequent
(62.5%; [Fig. 14 ]).
Fig. 14 Surgical maneuvers on the nasal base—resection of the alar base.
In the cerclage of the nasal base, the most commonly used thread was Mononylon 4–0
(83.33%) (Johnson & Johnson Medical, São Paulo, Brazil).
One hundred twelve patients returned in 12 months for follow-up and participated in
all the phases of the study. Fifty-eight patients did not complete the study.
Comparative Study of the Preoperative and Postoperative Anthropometric Measurements
of the Nose at 12-Month Follow-Up
Nasal Tip Projection
Goode's method was used through the measurement of the perpendicular line from the
tip point to the line of the facial plane divided by the measurement of the line from
the nasion to the tip point ([Fig. 3 ]). It is recognized that the value should be from 0.55 to 0.66. We found an increase
in the ratio in both sexes ([Table 1 ]). There are significant differences in the averages of the projection coefficient
between preoperative and postoperative phases in the total group and in both male
and female subjects.
Table 1
Preoperative and 12-month postoperative projection coefficient
Group/surgical phase
n
Projection coefficient
p
Min–max
Average
sd
Total/pre
112
0.60–0.68
0.63
0.02
0.00001
Total/post
112
0.61–0.68
0.65
0.01
Female/pre
75
0.61–0.68
0.63
0.02
0.00001
Female/post
75
0.61–0.68
0.65
0.02
Male/pre
37
0.60–0.68
0.63
0.02
0.000001
Male/post
37
0.62–0.68
0.65
0.01
Abbreviations: min–max, minimum and maximum value; post, postsurgical; pre, presurgical;
sd, standard deviation.
Nasolabial Angle
The nasolabial angle is the angular inclination of the columella at the point where
it meets the superior lip ([Fig. 2 ]). A nasolabial angle that varies between 90 and 120 degrees is considered ideal.
The average found for the nasolabial angle was higher for both sexes ([Table 2 ]).
Table 2
Preoperative and 12-month postoperative nasolabial angle
Group/surgical phase
n
Nasolabial angle
p
Min–max
Average
sd
Total/pre
112
65.3–138.5
97.50
12.86
<0.0001
Total/post
112
80.3–120.9
102.77
9.41
Female/pre
75
78.5–126.2
98.73
11.38
<0.0001
Female/post
75
80.3–120.9
104.08
9.16
Male/pre
37
65.3–138.5
95.00
15.30
Male/post
37
80.4–120.3
100.10
9.48
Abbreviations: min–max, minimum and maximum values; post, postsurgical; pre, presurgical;
sd, standard deviation.
There were significant differences in the averages of the nasolabial angle between
preoperative and postoperative phases in the total groups and in male and female patients.
Nasofrontal Angle
The nasofrontal angle is found by tracing a tangent line to the glabella through the
nasion, which crosses a line traced tangent to the nasal dorsum ([Fig. 2 ]). The ideal measurement varies between 115 and 130 degrees. We found an increase
in the angle in the male sex and a decrease in the angle of the female sex ([Table 3 ]). The differences of the nasofrontal angle averages between preoperative and postoperative
phases in the total group and in male and female patients were significant.
Table 3
Preoperative and 12-month postoperative nasofrontal angle
Group/surgical phase
Nasofrontal angle
p
n
Min–max
Average
sd
Total/pre
112
105.4–159.4
134.29
8.77
0.008
Total/post
112
120.3–142.2
132.24
3.61
Female/pre
75
111.9–159.4
135.71
7.28
0.00002
Female/post
75
125.0–142.2
132.31
3.38
Male/pre
37
105.4–149.1
131.41
10.75
0.67
Male/post
37
120.3–139.2
132.11
4.09
Abbreviations: min–max, minimum and maximum value; post, postsurgical; pre, presurgical;
sd, standard deviation.
Discussion
In a Brazilian journal, Patrocínio et al showed the importance of the surgical record
and the knowledge of the surgical techniques performed in rhinoplasty.[8 ] In our study, we recorded all the surgical techniques performed and we evaluated
the most frequently used ones on the nasal dorsum, on the nasal tip, and on the nasal
base. Because noses in our region are mostly Caucasian, which were the aim of our
study, our results are different regarding the accesses, the types of grafts on the
nasal tip, and the frequency of surgery on the nasal base compared with the findings
by Patrocínio et al.[8 ]
The findings regarding the evolution of patients made it possible for us to identify
the best techniques to achieve excellence in our results. The postoperative follow-up
of the patient is essential for the analysis of the results; the doctor-patient relationship
is important even in the presence of unsatisfactory results.
Standardized photographic documentation is essential; preoperative and postoperative
photos serve to document the results.
The scarring process of the nose is directly related to the surgical trauma, to the
type of skin, the type of cartilage, and postoperative care.
International magazines on facial plastic surgery advise the need to restrict qualitative
evaluations and to increase quantitative evaluations more objectively with the use
of tools such as the Rhinoplasty Outcomes Evaluation.[9 ]
Nasal measurements, despite providing objective data of the evaluation, are not more
important than the patient's satisfaction. Both pieces of information are important
for the patient's postoperative follow-up.
According to a study performed by McKiernan et al in 2001,[10 ] the impact of rhinoplasty in the quality of life can be evaluated through tools
such as the Glasgow Inventory. In the last decade, the quality of life has been a
common matter of discussion, and rhinoplasty has a highly positive impact on the functional
purpose as well as on the aesthetic one.
Leong and White stated that the interalar and intercanthal ratio is calculated through
the division of the interalar distance by the intercanthal distance ([Fig. 1 ]).[6 ] The ideal interalar-to-intercanthal ratio of the Caucasian nose is considered as
1, that is 100% equivalent ([Table 4 ]). In our study, the average postoperative proportion in the male group, the female
group, and total group was lower when compared with the same group preoperatively
(p > 0.05), approaching the ideal values.
Table 4
Preoperative and 12-month postoperative interalar and intercanthal distances
Proportion of interalar and intercanthal distances
Group/surgical phase
n
Min–max
Average
sd
p
Total/pre
112
0.75–1.58
1.12
0.15
0.00004
Total/post
112
0.75–1.42
1.08
0.13
Female/pre
75
0.81–1.55
1.10
0.15
0.002
Female/post
75
0.81–1.41
1.07
0.12
Male/pre
37
0.75–1.58
1.15
0.16
0.009
Male/post
37
0.75–1.42
1.09
0.14
Abbreviations: min-max, minimum and maximum value; post, postsurgical; pre, presurgical;
sd, standard deviation.
According to Goode's method, the ideal nasal projection is a 0.67 ratio. In our study,
we observed increased nasal projection at 12 months postoperatively (p < 0.05), being closer to the aesthetic ideal of the nose.
Several authors stated that the ideal nasolabial angle should be found between 90
and 120 degrees, but some authors suggest that it should be kept between 90 and 105
degrees. It is a consensus, however, that the measurement of the male nose should
have a more angle and the female nose should have a more obtuse angle, promoting higher
rotation on the nasal tip in women.[11 ]
[12 ]
[13 ]
[14 ]
In a population study in the city of Dundee, Scotland, Leong and White found a value
between 67 and 116 degrees.[6 ] In our study, the average of value was 97.50 ± 12.86 preoperatively and 102.77 ± 9.41
postoperatively (p < 0.05), showing an increase in the nasolabial angle and in conformity with the ideal
aesthetic values for a Caucasian nose.
In our study, the average nasofrontal angle postoperatively in the female group was
lower than the average preoperative value (p > 0.05), which probably occurred due to the reduction of the nasal dorsum through
surgical maneuvers such as the removal of the osteocartilaginous hump, approaching
the ideal values for the Caucasian nose mentioned by Leong and White.[6 ]
It is important to remember that the facial static morphology, despite being the dominant
factor in the aesthetic criteria, is not the only factor to be considered. Therefore,
dynamic proportions, skin texture, and color as well as the appearance of teeth are
also important in facial aesthetic.[7 ] For that reason, a multidisciplinary team becomes necessary with the aid of dermatologists,
orthodontists, and bucomaxillofacial surgeons, among others. In addition, in the final
evaluation, more than the standard aesthetic measurements, the most important thing
is that the patient's desire in sync with the surgeon's aesthetic sense.
The learning curve is based on the development of tactile skills and on the surgeon's
judgment. Surgical success is based on the systematization of surgical steps, the
level of search for excellence of new technical details, and surgical maneuvers that
are being improved, through sutures and grafts, always striving for the best refinement
for the Caucasian nose.
This study begins the research of the records of surgical maneuvers in rhinoplasty
and of the standardized objective evaluations of the surgical results at the hospital.
Conclusion
The main surgical techniques in rhinoplasty on Caucasian noses were studied and are
currently vast. The anthropometric evaluation at 12-month follow-up of the nose showed
quantitatively the efficacy of the procedures performed when compared with the ideal
aesthetic measurements for a Caucasian nose.
