Saddle nose rhinoplasty
Patients who are poor candidates for rhinoplasty in general, including unhealthy patients with poor perioperative risk profile and patients whose ability to follow the postoperative care regimen is limited (ie, patients with severe schizophrenia). Overresection of septal cartilage can lead to collapse of the middle vault and saddling. Removing too much septal cartilage can compromise the structural integrity of the dorsal L-shaped strut and increase the probability of postoperative or traumatic saddling of the nasal dorsum. No cartilage should be resected anterior to an imaginary vertical line drawn from the rhinion (osseocartilaginous junction) to the nasal spine. During septal cartilage resection, leaving a minimum of a 10-mm dorsal-caudal L-shaped margin of cartilage is important. Arching the incisions, instead of creating right-angled corners, can also impart slightly greater structural integrity to the dorsal L-shaped strut. Wegener granulomatosis is characterized by necrotizing granulomas and vasculitis of the upper and lower respiratory tracts, including the nasal septum. The cycle of necrotizing granulomatous lesion and microabscess formation leads to cartilage destruction. [ 2 ] In 1896, Israel applied a tibial bone graft to the nose. Treatment of the saddle-nose deformity tested the creativity of early nasal surgeons like Jacques Joseph. The treatment of saddle-nose deformities has continued to benefit from the contributions of countless pioneers of nasal surgery in the 19th century and masters of rhinoplasty in the 20th century. The most common cause is nasal trauma. It is characterized by a loss of height of the nose, because of the collapse of the bridge. The depressed nasal dorsum may involve bony, cartilaginous or both bony and cartilaginous components of the nasal dorsum. Patient with a history of relapsing polychondritis and severe saddle-nose deformity (type 4). In relapsing polychondritis (see the images below), recurrent episodes of autoimmune cartilage inflammation and destruction result in damage to the cartilaginous structure of the ears, nose, larynx, trachea, and peripheral joints. In this rare disease, fibrotic tissue replaces collagen, elastin, and other matrix proteins found in normal cartilage; this process leads to the loss of healthy cartilage. In-depth knowledge of the nasal anatomy is essential. The morphologic changes observed in a saddle nose are due to the loss of nasal skeletal support structures. These pathologic processes are discussed in the Pathophysiology section. The osseocartilaginous support framework includes the nasal bones, the upper and lower lateral nasal cartilages, the septum, the premaxilla, and their attachments to each other (see the first image below). The nasal septum plays a robust role in supporting the middle and lower thirds of the nose (see the second image below). Lateral view of the face with a saddle nose deformity far up on the bridge due to granulomatosis with polyangiitis using a nasal prosthesis. Persons who abuse drugs intranasally and who have not demonstrated at least 12 months of sobriety (Nasal reconstruction is contraindicated in patients who have not definitively demonstrated complete rehabilitation from their substance abuse.). Coordes A, Loose SM, Hofmann VM, et al. Saddle nose deformity and septal perforation in granul Close-up view of auricular cartilage damage secondary to relapsing polychondritis with a saddle nose in the background. Last edited on 20 February 2019, at 22:20. Upon physical examination, the degree and location of saddling, the state of the nasal septum, the status of the internal and external nasal valves, and the structural integrity of the nasal support structures must be evaluated. A higher rate of septal perforations is found in patients who have a saddle noses. Endoscopic nasal examination can facilitate an accurate survey of all endonasal structures. The standard series of photographs should be obtained prior to surgical planning for rhinoplasty. Persons with contraindications for repairing a saddle-nose deformity include the following:. Surgical overreduction of a nasal dorsal hump can produce an overly concave nasal dorsum. Additionally, an unidentified open roof deformity can further contribute to middle vault depression. Disharmonious changes in the nasal contour (eg, an overly projected nasal tip, an exaggerated supratip break) can also impart the impression of saddling. Inadequate support of the upper lateral cartilages and the middle vault may lead to its settling and relative saddling of the middle vault with time. A number of medical conditions affecting the nose can result in damage to the septum and cartilaginous structures. The common pathway is damage to the cartilage; compromise in the structure; and various degrees of subsequent nasal dorsal saddling, as clinically observed. A number of conditions can affect the nasal septum and lead to a saddle-nose deformity. An image depicting saddle nose deformity can be seen below. Regardless of the etiology, categorizing the severity of the saddle nose is helpful. The authors use a simplified system that classifies saddle-nose deformities on the basis of the anatomic deficits (see the image below), as follows: Won TB, Kang JG, Jin HR. Management of post-traumatic combined deviated and saddle nose deformity. Acta Otolaryngol. 2012 Jun. 132 Suppl 1:S44-51. [Medline]. The prevalence of saddle-nose deformities is difficult to assess. The prevalence is higher in population groups prone to facial trauma (ie, boxers, criminals, athletes), in persons with a history of intranasal cocaine use, and in individuals with a history of nasal surgery (eg, radical submucous septal resection, reductive rhinoplasty). A flat or concave nasal dorsal contour can resemble a saddle nose and is more prevalent in certain familial and racial groups. Some saddled noses may be more subtle, owing to thickened nasal skin soft-tissue envelope.