nasal surgery, Dr. Alireza Ghassemi

1. British Journal of Oral and Maxillofacial Surgery 53 (2015) 44–48
Available online at www.sciencedirect.com
Use of aesthetic rhinoplasty procedures in reconstructive
nasal surgery
Alireza Ghassemia,∗, Albert Rübbenb, Behnam Bohlulic,
Frank Hölzlea, Mehrangiz Ghassemid
a Department of Oral, Maxillofacial of Surgery, University Hospital of RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
b Department of Dermatology, University Hospital of RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
c Craniomaxillofacial Research Center, Azad University of Tehran, Tehran, Iran
d Department of Orthodontics, University Hospital of RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
Accepted 15 September 2014
Available online 5 November 2014
Abstract
Resection of cancer often involves the excision of underlying hard tissue, and some procedures in aesthetic rhinoplasty can be used in
reconstructive nasal surgery to increase the margin of safety while still achieving an acceptable aesthetic and functional outcome. We have
used techniques from aesthetic rhinoplasty to shape the nasal framework. Osteotomy and formation of the tip were used in 17 patients with
defects (ranging from 1 to 3.5 cm in size) from the nasal root to the tip of the nose. After the underlying bony or cartilaginous framework,
or both, had been removed, the resulting open roof deformity had to be corrected by osteotomy of the bony nasal wall and the tip shaped
by excision and suturing, including insertion of the tip graft and columellar strut graft. After this, and narrowing of the nose, the defect
was smaller and could be closed with local tissue without tension. There were no deformities in the contour, and patency of the airway
was maintained. Patients were satisfied with both the aesthetic and functional results. Although the margin of safety was increased, shaping
the nasal framework reduced the size of the defect, which allowed tension-free closure with a local flap. The operation requires a thorough
knowledge of procedures used in aesthetic rhinoplasty.
© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Tumour excision; Hump removal; Osteotomy; Tip-forming; Local flap
Introduction
Nasal reconstruction has always been a challenge for recons-
tructive surgeons, and the use of a local flap provides the
best options for colour, texture, and thickness. A successful
reconstruction of the bony and cartilaginous scaffold should
achieve a harmonious appearance.
∗ Corresponding author. Klinik für Zahn-, Mund-, Kiefer- und Plastis-
che Gesichtschirurgie, Universitätsklinikum RWTH-Aachen, Pauwelsstr.
30, 52074 Aachen, Germany. Tel.: +49 241 8088247; fax: +49 2418082430.
E-mail address: aghassemi@ukaachen.de (A. Ghassemi).
A simple improvement in the nasal contour can have an
appreciable impact on the overall appearance of the nose
and on the patient’s self-confidence. Refinements have been
suggested to minimise any noticeable deformity,1,2 but the
complexity of nasal contours is a challenge that demands the
refinement of existing procedures.3,4
During past decades there have been considerable
advances in reconstructive surgery. Existing methods have
been refined and new methods have been developed,
including the use of microsurgical tissue transfer.5–8 The
introduction of aesthetic nasal “subunits”, although contro-
versial, has contributed greatly to these refinements.9–12
http://dx.doi.org/10.1016/j.bjoms.2014.09.011
0266-4356/© 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

2. A. Ghassemi et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 44–48 45
Fig. 1. Left lateral view of a 58-year-old woman after excision of a basal cell
carcinoma from the tip of her nose (published with the patient’s permission).
Many variables, including the size and site of the defect,
the shape of the nose, and the laxity of the covering skin,
are important determinants of the choice of reconstructive
technique. Osteotomy of the nose is an essential step in aes-
thetic rhinoplasty to correct an open deformity of the nasal
roof and an irregular nasal wall, or to narrow the width of the
nasal base.13 Many procedures have been developed to shape
the tip of the nose.14,15 Excision of the tumour and raising a
flap permit wide exposure of the nasal bones and cartilage.
This allows exact manipulation of the nasal framework under
direct vision.
Here we present our clinical experience in the adjust-
ment of the nasal framework after excision of a tumour using
osteotomy and tip-forming techniques. The method was used
to increase the margin of safety and reduce the size of the
nasal defect to allow primary closure of the residual defect.
Patients and methods
We studied 17 patients with malignancies of the nose (7 men
and 10 women, mean age 65 (range 37–83) years). After
resection of the tumours with clear margins, the size of the
defects, which were on the nasal dorsum from the base to
the nasal tip, ranged between 1 and 3.5 cm. This included
resection of the underlying bony or cartilaginous (or both)
framework of the nose. For 5 patients we used unilateral or
bilateral advancement flaps from the cheek. Four had bilobed
flaps. We chose tissue from the nasal dorsum for 8 patients
(Figs. 1 and 2). Tension-free closure was achieved satisfac-
torily in all. We used a nasal osteotomy to correct the open
roof deformity, a large carbide burr was used to flatten the
nasal base, and a small diamond burr was used for the lateral
osteotomy. The procedure was done under local anesthesia
in 9 patients, and under general anaesthesia in 8.
Fig. 2. Photograph of the same patient after excision of the tumour with an
adequate margin of safety. The design of the flap is marked on the dorsum
of the nose (published with the patient’s permission).
Results
A good aesthetic outcome was achieved in all 17 patients with
no major complications. In the cases where an advancement
flap from the cheek was considered, secondary debulking
was required to improve the nasolabial region. An open roof
deformity, resulting from removal of the hump (Fig. 3), was
corrected by lateral osteotomy of the bony nasal wall (Fig. 3).
The osteotomy was easily done with a diamond burr after the
planned local flap had been dissected. This allowed accu-
rate and precise control of the path of the osteotomy and the
positioning of the bony lateral wall under direct vision. This
approach allows various types of nasal osteotomy – lateral,
medial, or transverse – as necessary.
The osteotomy line was smooth and allowed a predictable
split exactly as planned, and there were no unfavourable or
comminuted fractures. The infracturing was achieved by gen-
tle pressure with the fingers. The stability of the nasal wall
was maintained and tearing of the nasal mucosa avoided.
Fig. 3. After flap dissection, excision of the hump, and lateral osteotomy
made with a diamond burr.

3. 46 A. Ghassemi et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 44–48
Fig. 4. Photographs taken after 8 months: (a) patient’s left lateral view, (b) patient’s right lateral view, and (c) the patient’s view from below (published with
the patient’s permission).
Lateral osteotomy, followed by digital infracturing, nar-
rowed the width and reduced the size of the defect. In
addition, the reduction of the cranial part of the lower lateral
cartilage and the tip-suturing techniques that we used also
reduced the size. These procedures allowed the tension-free
reconstruction of the defect by local procedures (Fig. 4a–c).
All patients were satisfied with the result, whereas preopera-
tively they had been anxious about a possible deformity.
Discussion
Nasal reconstruction comprises controlled changes in the
skeletal support structures and the soft tissue envelope to
achieve the desired results. Improvement in the nasal contour
has an appreciable favourable impact on the patients’ overall
appearance and self-confidence. There has been an increas-
ing demand for optimal aesthetic and functional outcomes,
so various techniques have been suggested for replacement
of the soft tissue lost after resection of the cancer, depending
on the size and site of the defect and the tissue involved.2–8
Advances have been made during the past decade to achieve
the best possible results in reconstructive rhinoplasty. Burget
and Menick introduced the “subunits” philosophy to improve
the aesthetic outcome.10 Use of the nasal mucosa has also
optimised the result of reconstruction in perforated defects.16
Nevertheless, there is a need for further improvement in the
results, and simplification of the procedure.

4. A. Ghassemi et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 44–48 47
A small residual deformity of the nose can be seen, but
even a small improvement can have a favourable impact on
the patient’s quality of life.1,2 If the principles of aesthetic
and functional nasal surgery are followed, it can result in an
outstanding repair, so the use of the appropriate technique
will help to achieve the desired result.3,4
Skeletal support of the nose provides the main aesthetic
and functional requirements of nasal reconstruction. It is
the framework that provides the support and shape of the
covering soft tissue,5 and the restoration of the nasal con-
tour is integrally related to the composition and design of
the nasal framework. The principles of reconstruction of the
skeletal support are similar to those of aesthetic rhinoplasty,
and we have shown the importance of different techniques
that are commonly used in aesthetic rhinoplasty to shape the
nasal framework. In addition, these techniques can be used
to reduce the size of the defect, allow easier replacement of
tissue, and help to increase the margin of safety.
An alteration in the width of the nose by lateral osteotomy,
which is a usual part of aesthetic rhinoplasty, can be used in
reconstructive nasal surgery.13 It is an integral part of rhino-
plasty, and can be used to reshape the lateral contour, narrow
the base, realign the dorsum, and correct an open roof defor-
mity. Various methods and instruments have been introduced
for this purpose.17–22 The osteotomy should be controllable,
predictable, and easy to do.23
Depending on the site of the tumour, bone or cartilage
from the dorsum or cartilage from the nasal tip has to be
sacrificed to increase the margin of safety. This may lead to
an open roof deformity, which can be corrected by osteotomy
of the nasal wall. Once the soft tissue cover of the nose has
been dissected to close the defect, the osteotomy can be made
under direct vision, which is controllable and precise with a
limited potential for complications such as damage to the
surrounding soft tissue. It can be done with an appropriate
surgical burr.22,24 Tip-forming techniques used in aesthetic
rhinoplasty can also help to shape the nasal tip, reduce the size
of the defect, and achieve an adequate margin of safety.14,15
After the lateral nasal wall is in position, various local
flaps can be used to close the defect without leaving a visible
deformity. We have been using these procedures, includ-
ing osteotomy and tip-forming techniques, as an important
adjunct to other techniques in reconstructive nasal surgery to
improve the result.
Because the osteotomies were made under direct vision,
they could be made exactly along the planned path. The
use of a diamond burr allows the required osteotomy to
be made exactly and easily – lateral, median, or transverse
– without damaging the nasal mucosa or causing a com-
minuted fracture pattern. We encountered no irregularities
of the dorsum, the nasal wall did not collapse, and there
were no unwanted fractures, which can cause comminuted
fractures and spicules. The establishment of the normal sub-
surface architecture of the nose is essential to improve the
definition of nasal landmarks, even if the missing anatomy
has been precisely duplicated. An adequate local flap with
sufficient mobilisation and narrowing of the hard-tissue
reduces the tension and improves the accuracy of the inser-
tion of the flap. A soft tissue envelope similar in appearance
to the surrounding skin creates the visual impression of nor-
mality. The patient’s preoperative fear of having a deformed
ugly nose could be changed to postoperative satisfaction, so
we were able to help to relieve the problems of excision of a
cancer. Even the relatives were astonished.
We conclude that the techniques of aesthetic rhinoplasty,
from osteotomy of the nasal wall to formation of the tip, are
useful refinements that can optimise the outcome of recons-
tructive nasal surgery.
Conflict of interest
We have no conflict of interest.
Ethics statement/confirmation of patient’s permission
The patient has given us permission to publish the pho-
tographs.
We have no financial interest and we did not have any
financial or material support concerning this study.
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