58
labial complex and (3) show the results of the associa- tion 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 mid- line of the upper lip, extending up to the nose septum region, where it is formed by three fascicules, de- scribed as follows [6, 7] (Fig. 58.1) :
Medial fascicles: Together, the internal fascicles of the nasal septum depressor muscle have an equilat- eral triangular shape, with the bone insertion in the 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 concern- ing 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 suc- ceeded 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 expe- rience 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-
Search for Balance Between the Nose Tip and the Upper Lip
Ewaldo Bolívar de Souza Pinto, Priscila C.S.P. Abdalla, Rodrigo P.M. de Souza, Eduardo Hentschel, Sergio Pita
Fig. 58.1. Fascicles of the nasal septum depressor muscle: a Lateral fascicle;
b intermediate fascicle; c medial fascicle
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 re- leased 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 in- termediate fascicules.
Intermediate fascicles: These are placed between the medial and lateral fascicles; they have a funda- mental role in the dynamic rhinoplasty (enlarging or reducing the upper lip) when they replace the medial fascicles, being plicated towards the midline.
Lateral fascicles: 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 develop- ment, Souza Pinto proposed a classification for pa- tients 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 impor- tant to pay attention to some details:
– Thorough anamnesis with patient data indica- tions
– Physical examination, observing the functional and anatomic features
– Still and dynamic photographic study (patient smiling) to assess the nasal septum depressor mus- cle’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 pa- tient–doctor rapport [12].
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, aes- thetic nose feature analysis is performed according to the individual needs of each patient. Concern- ing 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 resec- tion 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 45–
60°) 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 adrena- line solution.
3. Zetaplasty mucosal incision followed by the un- dermining 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 Table 58.1. Dynamic rhinoplasty – Souza Pinto classification
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)
tutes the main step in the technique of dynamic rhinoplasty, where the muscular fascicules are ap- proached and treated on the basis of the semiotic group involved.
With the help of a retractor, perform a periostal un- dermining; the medial fascicle is totally freed from the lower part of the nasal spine, with consequent lift- ing of the nose tip, resulting in a projection of the up- per lip (Fig. 58.3).
With the improvement of techniques for the mus- cular treatment of the nose tip and upper lip we con- cluded 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 projec- tion 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 de- mands of each case.
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
Fig. 58.4. Central displacement and plicature of the inter-
mediate fascicle Fig. 58.5. Zetaplasty: transposition of the mucosal flaps; clo- sure with absorbable suture.
58.5 Results
Through the dynamic rhinoplasty it is possible to treat the nasolabial complex, obtaining a more har- monious result. The association of functional (septo- plasty and turbinectomy) and aesthetic (rhinosculp- ture) surgery leads to more satisfactory results.
The association of techniques for a 23-year-old pa- tient 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 dor- sal 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. 58.6. a Preoperatively.
b Six months after surgery
Fig. 58.7. 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 correc- – Columella projection with an important reduction tion
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 sur- gical 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, ac- cording to the principles of rhinosculpture, individu- ally considering each case and avoiding the stigma of an operated nose.
Fig. 58.8. a Preoperatively.
b Six months after surgery
58.7 Conclusion
We have been performing rhinosculptures since 1993, always trying to individualize our procedures in or- der to achieve harmony between the nose and the face, not leaving obvious signs of a surgery to the pa- tient.
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 dy- namic surgery for this segment in particular, which has a close connection with the upper lip. Working with the nasal septum depressor muscle and its fasci- cles 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 cas- es 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.
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