AmeriCorps Health Blog

Anterior Nasal Spine Surgery

Ewaldo Bolívar de Souza Pinto, Priscila C.S.P. Abdalla, Rodrigo P.M. de Souza, Eduardo Hentschel, Sergio Pita

58.1

Introduction

The study of the anatomy of the nasolabial region has been very important in the last few years because it has contributed to the aesthetic rhinoplasty concerning the search for harmony between the nose and the upper lip, and more importantly, the smile [1].

Inspired by other surgeons' experience in the treatment of Negroid nose, in which the substantial subperiosteal displacement for the relaxation of the lateral musculature is indicated [2], the authors succeeded in freeing and treating the fascicules of the nasal septum depressor muscle through the upper gingiva, performing a zetaplasty in the oral mucosa [3-5].

This chapter aims to (1) present our surgical experience in the functional and dynamic treatment of the muscles closely related to the nose tip and the upper lip, (2) establish a semiotic classification of the naso labial complex and (3) show the results of the association of functional rhinoplasty (septoplasty, turbinec-tomy) and aesthetic surgery (rhino sculpture).

58.2

Anatomy

There has been an increase in interest in the study of the functional anatomy of the nose muscles [6, 7]. The nasal septum depressor muscle is considered to be the main muscle involved in the dynamic drop of the nose tip, especially when the subject smiles [2-4, 8-10]. It is a muscle localized in both sides of the midline of the upper lip, extending up to the nose septum region, where it is formed by three fascicules, described as follows [6, 7] (Fig. 58.1) :

Medial fascicles: Together, the internal fascicles of the nasal septum depressor muscle have an equilateral triangular shape, with the bone insertion in the

lower portion of the nose spine (triangle apex) and the triangle base with a free insertion in the upper lip. During a dynamic rhinoplasty, these fascicles are released from their bone insertions in order to reduce the muscular strength, lift the nose tip and enlarge the upper lip. Afterwards they are replaced by the intermediate fascicules.

Intermediate fascicles: These are placed between the medial and lateral fascicles; they have a fundamental role in the dynamic rhinoplasty (enlarging or reducing the upper lip) when they replace the medial fascicles, being plicated towards the midline.

Lateralfascicles: The nostrils are especially large in Negroid noses, widening the nose wings. They can be freed and twisted towards the center, narrowing the nostril base.

58.3

Semiology

Following up on the dynamic rhinoplasty development, Souza Pinto proposed a classification for patients in six different groups, indicating the specific surgery technique to each one of them (Table 58.1).

This classification is based on the relation between the nose tip characteristics (drooping or projected) and the upper lip (short or long) for groups I-IV ; groups V and VI are considered special cases.

During the preoperative preparation it is important to pay attention to some details:

• Thorough anamnesis with patient data indications
• Physical examination, observing the functional and anatomic features
• Still and dynamic photographic study (patient smiling) to assess the nasal septum depressor muscle's action on the nose tip
• Routine laboratory tests
• Preanesthetic assessment

Computerized studies were first performed in 1988 and have been continuously improved with hardware and software resources, trying to improve the patient-doctor rapport [12].

Table 58.1. Dynamic rhinoplasty - Souza Pinto classification

58.4

Techniques for the Treatment of a Short Upper Lip

After the arrival of dynamic rhinoplasty, the surgery can be divided into four distinct phases:

1. Septoplasty: In cases where there is some kind of septum deviation, surgery is initiated with the functional disorder correction.
2. Dynamic rhinoplasty: This represents the second phase of the surgery, with its own peculiarities for each semiotic group involved.
3. Rhinosculpture [13]: After the septoplasty and the nose tip and upper lip muscular treatment, aesthetic nose feature analysis is performed according to the individual needs of each patient. Concerning the nasal base and dorsum, for example, the surgeon can perform bone and cartilage abrasion, resection, osteotomies and cartilage grafting. In order to improve the nose tip, one can minimally resect the alar cartilage, graft cartilage in the tip or at the nasolabial angle or resect wedges of the alar cartilages in the case of Negroid noses.
4. Turbinectomy: In the case of hypertrophy of the cornets, functional turbinectomy (partial resection of bone and mucosa) is performed at the end of the surgery.

The surgical technique referred to as dynamic rhino-

plasty and the resultant muscular treatment of the short upper lip are described as follows:

1. Marking: After overthrowing the upper lip, the marking of the zetaplasty is performed (angle 4560°) in the labial bridle of the gingival mucosa in the upper lip (Fig. 58.2).
2. Local anesthesia with infiltration of a solution composed of 1% lidocaine and 1:100,000 adrenaline solution.
3. Zetaplasty mucosal incision followed by the undermining of mucosal flaps.
4. Dissection and identification of the nasal septum depressor muscle's fascicles bilaterally. This consti

Fig. 58.2. Marking the zetaplasty (45-60°) in the upper lip

Group I: Drooping nose tip and short upper lip

• gingival smile) Group II: Drooping nose tip and long upper lip Group III: Projected nose tip and short upper lip
• gingival smile) Group IV: Projected nose tip and long upper lip Group V: Negroid nose (special case) Group VI: Mouth breather (special case)

58 Search for Balance Between the Nose Tip and the Upper Lip

58 Search for Balance Between the Nose Tip and the Upper Lip

Fig. 58.3. a Subperiostal undermining of the medial fascicle of the nasal septum depressor muscle with the aid of a retractor. b Medial fascicle freed from the anterior nasal spine

tutes the main step in the technique of dynamic rhinoplasty, where the muscular fascicules are approached and treated on the basis of the semiotic group involved.

With the help of a retractor, perform a periostal undermining; the medial fascicle is totally freed from the lower part of the nasal spine, with consequent lifting of the nose tip, resulting in a projection of the upper lip (Fig. 58.3).

With the improvement of techniques for the muscular treatment of the nose tip and upper lip we concluded that there is no necessity for bone resection below the nasal spine. The next step is undermining the intermediate fascicles in the mucosal plane with delicate scissors, and centrally repositioning them in the midline with the plicature of its bands, replacing the medial fascicles previously freed (Fig. 58.4).

This central plicature allows the columella projection and nose tip lifting, isolating it, functionally, from the upper lip.

After hemostasis, the mucosal flaps are transposed and sutured with absorbable suture, allowing the elongation of the upper lip (1-2 mm) (Fig . 58.5).

Specific precautions regarding the postoperative follow-up of this surgery include strict and proper mouth hygiene. Recommendations concerning the aesthetic (rhinosculpture) and functional surgery (septoplasty and turbinectomy) are based on the demands of each case.

Fig. 58.4. Central displacement and plicature of the inter- Fig. 58.5. Zetaplasty: transposition of the mucosal flaps; clo-mediate fascicle sure with absorbable suture.

Fig. 58.6. a Preoperatively. b Six months after surgery

58.5 Results

Through the dynamic rhinoplasty it is possible to treat the nasolabial complex, obtaining a more harmonious result. The association of functional (septoplasty and turbinectomy) and aesthetic (rhinosculp-ture) surgery leads to more satisfactory results.

The association of techniques for a 23-year-old patient with a drooping nose tip, a short upper lip, an obvious dorsal convexity and septum deviation re sulted, 6 months after surgery, in the improvement of the dorsal contour, upper lip elongation and nose tip lifting (Fig. 58.6).

Figure 58.7 shows a 21-year-old patient with a dropping nose tip drop, a short upper lip and dorsal convexity, and the postoperative result after 6 months.

In Fig. 58.8, we show a 19-year-old patient, a mouth breather, with a gingival smile, a drooping nose tip, an exuberant dorsal convexity, septum deviation and a short upper lip. Six months after the surgery we notice a more harmonious and projected profile.

Fig. 58.8. a Preoperatively. b Six months after surgery

58.6

Discussion

At the beginning, this technique, currently known as dynamic rhinoplasty, was used in cases of severe drooping nose tips, patients with a gingival smile, a short upper lip, columella retraction and a Negroid nose. The main achievements observed with the use of this technique are:

• Nose tip lifting and its functional isolation from the upper lip
• Upper-lip elongation and gingival smile correction
• Columella projection with an important reduction in the need for cartilage grafting in the nasolabial angle

Narrowing of flared nostrils in the case of a Negroid nose

The dynamic rhinoplasty represents only one of the nose surgery stages. When compared with other surgical procedures its advantages are:

• Need for minimal incisions
• Muscular functional treatment of the nose tip
• Significant reduction in the need for cartilage grafting

We still emphasize, however, the importance of the association of aesthetic and functional treatments in order to preserve the facial harmony as a whole, according to the principles of rhinosculpture, individually considering each case and avoiding the stigma of an operated nose.

58 Search for Balance Between the Nose Tip and the Upper Lip 441

58.7

Conclusion

We have been performing rhinosculptures since 1993, always trying to individualize our procedures in order to achieve harmony between the nose and the face, not leaving obvious signs of a surgery to the patient.

Encouraged by our work with the anatomical and muscular approach of the nose tip in rhinoplasty, we have been adapting the precepts of functional and dynamic surgery for this segment in particular, which has a close connection with the upper lip. Working with the nasal septum depressor muscle and its fascicles in distinctive ways in each semiotic case, one can achieve natural, functionally satisfactory and long-lasting results.

We have come to be very encouraged in the use of this technique, owing to the facial harmony achieved and the results that show us the improvement in the base-dorsum-nose tip-lip ratio. Used initially in cases of extremely drooping nose tips or Negroid noses, nowadays, this surgical technique is also indicated in cases of a long upper lip and a projected nose tip, and is available for use without restrictions.

References

1. De Souza Pinto EB, Rocha RP, Filho WQ, Neto ES, Zacharias KG, Amancio EA, Camargo AB. Anatomy of the Median Part of the Septum Depressor Muscle in Aesthetic Surgery. Aesth Plast Surg 22:111, 1998.
2. Santana PSM, Abel JL, Martinez PSM, et al. Negroid nose treatment, without excision of the nasal ala. Annals of the International Symposium Recent Advances in Plastic Surgery. Sao Paulo, Brazil; 384-389; March 3-5, 1989.
3. De Souza Pinto EB, Erazo IP, Queiroz FW. Rhinoplasty: treatment of the tip-columella and lip. Annals of the ISAPS-XIII International Congress, New York, September 28-October 3, 1995.
4. De Souza Pinto EB, Erazo IP, Muniz AC. Rinoescultura: tratamento da dinámica da ponta nasal, columela e lábio. In: Tournieux AAB, Curi MM. Atualiza^äo em Cirurgia Plástica - SBCP, 1st ed, Robe Editorial, Sao Paulo, 51-57, 1996.
5. De Souza Pinto EB, Erazo PJ, Muniz AC. Rinoescultura. Técnica personale. In: Ferrari F, Pitanguy I. Chirurgia Estética - Strategie preoperatorie. Technique chirurgiche. Vol. primo FACCIA, Editora Utet, Turin, 67-77, 1997.
6. Correa JPT, De Souza Pinto EB, Erazo IP. Estudo anatómico experimental da regiao nasolabial em cadáveres e sua importancia em rinoplastia. In: Tournieux AAB, Curi MM, eds. Atualiza^äo em Cirurgia Plástica - SBCP, Robe Editorial, Sao Paulo, 687-691, 1996.
7. Gonella HA. Contribuido ao estudo anatómico dos músculos do nariz. Tese Faculdade de Medicina de Sorocaba

- PUCSP, Sorocaba, Sao Paulo, Brazil, 1982.

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1. Ribeiro L, Accorsi A Jr. Parrot nose. Plastic Reconstructive and Aesthetic Surgery. Transactions of the 11th Congress of the International Confederation. Yokohama, Japan, 121-122, April 16-21, 1995.
2. De Souza Pinto EB, Erazo P, Muniz, AC. The nasal tip surgical treatment by performing the nasal septum depressor muscle mioplasty. Abstracts of the 14th Congress International Society of Aesthetic Plastic Surgery, Sao Paulo, Brazil, 245, May 31-June 3, 1997.
3. De Souza Pinto EB, Biirgel FL, Muniz AC. Ouso do Computador na Rinoescultura. In: Tournieux AAB, ed. Atual-iza^äo em Cirurgia Plástica Estética - SBCP, Robe Editorial, Sao Paulo, 201-205, 1994.
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