Osteotomies in Rhinoplasty - Types, Approaches, Steps & Complications

👃 Osteotomies in Rhinoplasty

📝 Definition of Osteotomy

Osteotomy is the controlled surgical fracture or cutting of the nasal bones to reposition them.

⭐ The word osteotomy literally means bone cutting.

What is the surgical anatomy of the nose in relation to rhinoplasty?

🎯 Purpose of Osteotomies in Rhinoplasty

1️⃣ Closure of the open roof deformity

What is open roof deformity?

2️⃣ Narrowing of a wide bony vault

3️⃣ Straightening a deviated bony pyramid

4️⃣ Correction of asymmetry of the nasal bones

📋 Types of Osteotomies

⭐ All types of lateral osteotomy narrow the airway to some extent.

What are the different types of Lateral Osteotomy? Describe each type.

What is Webster's Triangle? What is it's clinical significance?

🔍 Lateral Osteotomy - Steps

📍 Position of the Lateral Osteotomy

⭐ In the region of the root of the nose, a high osteotomy is preferred over a low osteotomy.

The space left behind after shifting the lateral wall inwards is later obliterated by the process of osteogenesis.

What dye is usually used for surface marking before lateral osteotomy?

A. Internal Approach

1️⃣ Local Anaesthetic Infiltration

2️⃣ Incision

• A stab incision about 0.5 cm in length, with a No. 15 blade
• Placed in the pyriform crest region, just in front of the attachment of the inferior turbinate

3️⃣ Elevation of the Periosteum

• Periosteum separated alongside the frontal process of the maxilla, creating a tunnel

4️⃣ Introduction of the Joseph's Saw

• Introduced carefully along the frontal process of the maxilla, along the nasofacial groove
• Teeth of the saw face against the bone for easy introduction and to avoid soft tissue injury
• Saw positioned at a right angle to the surface of the bone
• Patient's head is turned to the side and immobilized by the assistant

5️⃣ Sawing the Frontal Process

• The frontal process is sawed through its entire length in the nasofacial groove, without cutting the mucosa
• Movements of the saw are controlled and guided with the fingers of the left hand

What other alternative instruments are used in Lateral osteotomy other than Joseph's Saw?

What are the contraindications of Lateral Osteotomy?

B. External Approach

• A tiny stab incision is placed externally at the nasofacial groove

⚠️ The external scar may be visible later.

• The osteotomy cut is begun above the inferior turbinate on the pyriform crest, to save a triangular piece of bone

• Injecting anaesthetic inside and outside the bone before the cut minimizes bleeding and pain

• The osteotome or chisel is driven along the nasofacial groove, and from the infraorbital border an oblique cut is made towards the midline

What is Curved Lateral Osteotomy? What is the advantage of Curved Lateral Osteotomy?

🔍 Medial Osteotomy

The cut is given along the midline of the nasal dorsum, and may be oblique or vertical.

⭐ Used only in cases of significant deviation.

✅ Indications

• Bones do not fracture easily at the frontonasal suture after lateral osteotomy
• Need for satisfactory infracture or outfracture at the frontonasal suture
• When a straight lateral osteotomy has been used

❌ Contraindications

• Large hump removal, where the bone becomes mobile and weakened at the frontonasal area
• Curved lateral osteotomy, as the greenstick fracture extends along the frontonasal suture on its own

What are the steps of Medial Osteotomy in Rhinoplasty?

🔍 Transverse Osteotomy

Creates a transverse fracture at the frontonasal suture.

Internal Approach

• After completing the medial osteotomy cut, the same osteotome is rotated laterally
• The bones are outfractured from their attachment at the frontonasal suture
• The nasal septum is used as a fulcrum for the osteotome

👉 An audible and perceptible click indicates that the transverse fracture has been made.

External Approach

• Performed separately with a small chisel
• A stab incision is given on the upper part of the bony vault

⚠️ May result in an external scar.

🔨 Movement of the Bones After Osteotomy

1️⃣ The lateral bony wall is moved inwards, with the nasal bones and frontal processes of the maxilla pushed medially using the thumb and fingers

2️⃣ The nasal wall is steadied using a gauze piece, and the new position confirmed

3️⃣ The whole bridge of the nose is evaluated by inspection and palpation

4️⃣ Any bony irregularity is resected or smoothed with a bone rasp

What are the Causes of Difficulty in Moving the Bones Inwards After Osteotomy? How would you correct each of them?

⚠️ Complications of Osteotomies

• Rocker Formation

• Periorbital Ecchymosis & Edema

• Injury to the Medial Canthal Ligament or Lacrimal Sac

• Irregular Fracture at an Undesirable Site

• Step Deformity

• Dislocation of the Cephalic Border of the Upper Lateral Cartilage

• Nasal Obstruction

• Skin Puncture or External Scar

What are the causes behind each of the above complication of Osteotomy? How would you manage them?

⭐ Exam Pearls

• Osteotomy is the controlled surgical fracture of the nasal bones to reposition them
• Lateral osteotomy narrows the bony nasal vault
• Medial osteotomy separates the two nasal bones
• Transverse osteotomy is the upper limit of bone movement
• Curved lateral osteotomy produces a greenstick fracture and obviates the need for a medial osteotomy
• High osteotomy is preferred at the root of the nose
• Elevation of periosteum must be superficial to the medial canthus
• Medial osteotomy placed too medially → Rocker formation
• Transverse fracture is confirmed by an audible click

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