46. Elastic Rhinoplasty
KEYWORDS: elastic rhinoplasty, rhinoplasty with elastic thread, Elasticum, Jano needle, shortening of the tip of the nose
A long nose can be shortened, and the tip reshaped by implanting an elastic thread through a 2 mm incision.
Elastic lifting of the nose has not only an esthetic objective, but also a functional purpose. Indeed, by correcting the nasolabial angle, this procedure improves the patient's breathing.
A 2 mm incision is made at the point where the nasal bones meet the frontal bone. The preoperative design is drawn along the sides of the nose. The line is drawn between the curved surface of the bridge of the nose and the plane surface of the ascending processes of the maxilla. The line continues along the nose-tip, passing halfway between the upper extremity of the nostrils and the apex of the tip of the nose. The design is completed by marking the inferior margins of the ascending processes of the maxilla, which delimit the safest area of intervention.
An arrow is drawn to indicate the deviation of the septum, which can be corrected by means of a rhinofiller once the nose has been shortened.
An anti-staphylococcal antibiotic ointment is applied inside the nostrils. Local anesthesia is carried out at the base of the nasal pyramid. A third of a milligram of epinephrine is added to 10 ml of 2% lidocaine or 2% mepivacaine. A 2.5 ml syringe and a 4 cm long 27 G needle are used.
After anesthetizing the base of the nasal pyramid, the operator injects the anesthetic along the lower line of the design.
A skin incision is made with a microsurgery scalpel. A fine Klemmer is used to create a deep cavity to house the knot.
The two-tipped Jano needle is slightly curved. The tip of the needle is inserted in depth into the small incision and anchors the elastic thread (Elasticum EP4, Korpo) to the deep tissues of the procerus muscle. The needle partially emerges along the horizontal line of the design. The elastic thread is pulled through. As always, a Klemmer is fixed to the end of the thread.
The needle is extracted until 5 mm of the posterior tip remains in the tissues. It is then rotated and continues along its pathway, partially emerging on the line of the inferior margin of the ascending process of the maxilla. The elastic thread is pulled through. The needle is extracted until 5 mm of the tip remains in the tissues. It then rotates in the direction of the design. This is the point of passage from the bony portion of the nose to the cartilaginous portion. Along the anterior pathway between the two ascending processes of the maxilla, there is no longer a bony plane that can prevent the needle from accidentally piercing the nasal cavities. To facilitate the passage of the needle between the skin and the cartilages, the assistant uses a 2.5 mL syringe to inject a solution of local anesthetic immediately beneath the skin, in order to increase the distance between the skin and the underlying cartilaginous structures. This enables the two-tipped needle to pass through safely. The needle partially emerges from the tip of the nose. The elastic thread is pulled through. The anesthetic solution is then used to swell the pathway of the elastic thread over the alar cartilages. The Jano needle is extracted until less than 5 mm of the tip remains in the tissues. It then rotates and follows its pathway, partially emerging from the nose-tip. The elastic thread is pulled through and placed under tension. The two-tipped needle is partially extracted until less than 5 mm of the posterior tip remains in the tissues. It is then rotated and travels through the space between the skin and the cartilage. The Jano needle is again extracted and rotated in order to follow the preoperative design. Once in proximity to the entry incision, the needle partially emerges. The elastic thread is pulled through and placed under tension. When 5 mm of the posterior tip remains in the tissues, the needle anchors the thread to the deep tissues of the procerus and exits through the small incision. The two ends of the elastic thread are placed under tension and are knotted under the guidance of the tip of a Klemmer.
The small incision is sutured with an absorbable thread.
The result is optimal and stable over time. The acute nasolabial angle has been corrected.
After about two months, rhinofilling is carried out for the esthetic correction of the deviation of the nose, which has already been improved by lifting the tip.
Capurro S. (2020): Elastic Rhinoplasty. CRPUB Medical Video Journal. Elastic Plastic Surgery section, www.crpub.org.
Can elastic lifting of the nose be performed on all noses?
It can be performed on noses that have a mobile tip. Noses with very evident bony defects are not suited to this procedure; in such cases, we carry out traditional rhinoplasty. Elastic lifting of the nose can improve the appearance of a high percentage of noses that are deemed to be too long. This economical mini-invasive procedure makes "normal" noses look cute. The elastic thread can also be used to correct noses with an acute nasolabial angle that makes breathing difficult.
When the two ends of the elastic thread are placed under tension, do they have to be pulled hard?
Yes. Suspension of the nose-tip has to be "over-corrected". It must be borne in mind that there may be as much as 7 to 10 ml of anesthetic in the nose. When the anesthesia and the edema subside, the tip of the nose will descend by a few millimeters.
What recommendations are there after the procedure?
Before suturing the 2 mm incision, we often insert a hemostatic sponge into the cavity; this serves to maintain the knot in depth. Every day, the patient should apply an anti- staphylococcus ointment and a small sticking-plaster to the sutured incision. In the first few days, the ointment should also be applied to the nostrils. A "sling" sticking-plaster to support the nose-tip and a few plasters on the bridge of the nose complete the medication. The dressing will be redone every day. In the following weeks the nose must be washed thoroughly inside and out. The nasal region is not clean. 30% of patients are staphylococcal. This must be considered.
If there are alterations of the bridge of the nose, do you use a rhinofiller?
Pre-existing alterations of the bridge of the nose are normally attenuated after elastic suspension, and can be corrected by means of a rhinofiller. If there are small skin excesses these are corrected with local infiltrations of diluted cortisone.
What type of rhinofiller?
I use non-cohesive cross-linked hyaluronic acid diluted to 40%.
Is the result stable over time?
Yes, the Elasticum thread turns into a ligament and the result is perfectly stabilized
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