Assessment of Different Types of Osteotomies in Rhinoplasty Patients

INTRODUCTION
Rhinoplasty is challenging procedure as its one
of the aesthetic procedures where the patient and
all his acquaintances are constantly seeing and
judging the plastic surgeon outcome. Osteotomy
is one of the most crucial steps in order to have
good results; it is needed to narrow nasal width.
Osteotomy is also one of the difficult steps in
rhinoplasty as it is blind and meticulous [1].
The type of osteotomies usually can be decided
preoperatively; the critical factor is how much
movement of the lateral nasal wall is required to
narrow the bonybase width. If a great deal of
movement is necessary, then one needs complete
osteotomies with bony separation. In contrast if
one only needs a more limited narrowing, then a
65
greenstick fracture is sufficient. There are several
types of osteotomies that can be combined together
in order to achieve the desired width reduction
however, movement and stability of the lateral
walls are critical factors in the decision process
[2]. Fig. (1) shows different types of osteotomies.
• Lateral osteotomies:
A- Low to high osteotomy: Slightly curved
osteotome is placed low on the pyriform aperture,
then with two-tap sequenced pace its driven up
through frontal process of the maxilla to end high
at the nasal bone suture line at the level of the
medial canthus; followed by a digital compression
to produce transverse green stick fracture. Limited
movement will be achieved.
B- Low to low osteotomy: Straight osteotome
is driven along the base of the frontal process of
maxilla, not across it in an ascending fashion;
usually this technique is associated with transverse
osteotomy to allow complete movement of the
lateral nasal bones [3].
• Transverse osteotomies: A vertical stab incision
is made just above medial canthus, 2mm osteotome
is used to completely fracture the lateral
wall transversely from just above medial canthus
upward. Usually it is followed by low to low
osteotomy.
• Medial oblique osteotomies: A curved osteotome
is placed at the cephalic end of the open roof and
driven downward toward the medial canthus. It
is designed to narrow the broad bony dorsum and
is coupled with low to low lateral osteotomy [4].
• Double level osteotomies: Consists of an osteotomy
along the inferior border of the nasal bone
parallel to and combined with a low to low osteotomy.
The goal is to reduce the convexity of the
lateral wall [5].
• Paramedian osteotomies: Straight osteotomies
made 3-5mm parallel to the dorsal midline. It is
used in the broad nose when one does not wish
to change dorsal midline [6].
• Microosteotomies: Done with 2mm osteotome
and are used to correct asymmetries or irregularities
intrinsic to the bones [7].
66 Vol. 44, No. 1 / Assessment of Different Types of Osteotomies in Rhinoplasty Patients
were documented and tabulated. Follow-up for 6
months and evaluation sheet by was filled. 200
patients complied to follow-up, the rest (250 patient)
were excluded from the study. Comparative
evaluation of the results was done and statistically
analyzed.
Types of osteotomies used in this study:
- Green stick & median osteotomy: 62/200 cases,
low to low to high lateral osteotomy.
- Greenstick without median osteotomy: 68/200
cases, low to low to high osteotomy.
- Double level osteotomy: 30/200 cases, low to
high & low to low osteotomy.
- Full power osteotomy: 40/200 cases, low to low
to high osteotomy.
RESULTS
13% (26 cases) was total complication rate.
Complication varied from asymmetry: 4.5%, residual
hump: 6%, nasal bone collapse: 2%, extensive
displacement: 0.5%.
Fig. (1): Types of osteotomies. (A) Paramedian osteotomy.
(B) Medial oblique osteotomy. (C) Transverse osteotomy.
(D) Low to high osteotomy. (E) Double level
osteotomy.
Table (1): Complications of osteotomy.
Operative trauma
Hemorrhage
Edema
Nasal cyst formation
Anosmia
Arteriovenous fistula
Epiphora
Canicular bleeding
Neuromuscular injury
Intracranial injury
Cosmetic
Excessive narrowing
Insufficient mobilization
Unstable bony pyramid
Rocker deformity
Stair step deformity
Nasal bone asymmetry
Infections: Abscess, granuloma,
cellulitis.
Complications
6.00%
0.50%
2%
5%
Resid.Hump
Asymmetry
N.collapse
Ext.disp
Fig. (2A): Pie chart of complications.
Fig. (2B): Patient showing extensive displacement.
Osteotomy is usually done to narrow bony
vault, to close open roof deformity, to create symmetry
and to widen bony vault with lateral displacements
of nasal bones. Osteotomy is usually
critical when patients has short nasal bones, elderly
patients with thin, fragile nasal bones and patients
with heavy eyeglasses [8].
Complications of osteotomy are either operative
trauma or cosmetic complication, Table (1) [9]:
MATERIAL AND METHODS
Retrospective study from 2010 to 2014, including
450 patients. Pre-operative data were documented
and tabulated. Intraoperative data were
documented and tabulated. Post-operative data
Egypt, J. Plast. Reconstr. Surg., January 2020 67
Complications according to the type of osteotomy:
• Green stick & median osteotomy: 8 cases [8/62=
12.9%, 3 asymmetry, 4 residual hump, 1 extensive
displacement].
• Greenstick without median osteotomy: 5 cases
[5/68=7.3%, 2 asymmetry, 3 residual humps].
• Double level osteotomy: 6 cases [6/30=20%, 2
nasal bone collapse, 2 asymmetry, 2 residual
humps].
• Full power osteotomy: 7 cases [7/40=17.5%, 2
nasal bone collapse, 2 asymmetry, 3 residual
hump].
Fig. (4A): Pre-operative rhinoplasty case. Fig. (4B): Post-operative case after lateral greenstick osteotomy
without median osteotomy.
DISCUSSION
Osteotomy still remains one of the most crucial
and challenging steps in rhinoplasty. Therefore,
meticulous analysis of osteotomy results in 200
patients was conducted in this study. After tabulating
and analyzing the results the following was
concluded:
- Safest type of osteotomy is greenstick osteotomy
without median osteotomy.
- The next safest osteotomy is green stick with
median osteotomy.
- We found that asymmetry, residual hump & collapse
occur more with full power and double
level osteotomy.
- Low to high osteotomy usually leaves residual
step.
- Completion of fracture is done by thumb pressure
on small thin bones while thick bones is done
by mobilizing the osteotome.
- Our preference is green stick low to low to high
osteotomy, with or without median osteotomy.
Conclusion:
Osteotomy is one of the most crucial steps in
rhinoplasty. In this study we did retrospective
analysis of 450 rhinoplasty patients and their osteotomy
results. We concluded that lateral green
stick osteotomy with or without median osteotomy
is the safest osteotomy.
Fig. (3A): Bar chart of complications for each type of
osteotomy.
25.00
20.00
15.00
10.00
5.00
0.00
Gr.st.+med. Gr.stick D.L F.P
%
Fig. (3B): Bar chart comparing specific complication to each
type of osteotomy.
7
6
5
4
3
2
1
0
Gr.st.+med. Gr.stick D.L F.P