Secondary rhinoplasty : reconstitution of the allar cartillages by a rhinoplasty with an external incision

Classic endonasal rhinoplasty does not enable a symmetric ressection of the allar cartillages. Due to this, presence of secondary endonasal deformities is very frequent. Opening utilization, with a whole exposition of the cartillages, enabled an exact evaluation of deformities and, as a result, a more precise restoration. In all of the cases, wrong removals were observed, resulting in the most different types of deformity, ranging from since a small asymmetria until a complete collapse, with total ressection of the cartillages. After Rethi (4), Sercer (5), Padovan (3) and, most recently, Goodman (1 and 2), Sheen (6), divulgated rhinoplasty through nose openings, we have observed that treatment of the secondary deformities as well as some


INTRODUCTION
C lassic endonasal rhinoplasty does not enable a symmetric ressection of the allar cartillages.Due to this, presence of secondary endonasal deformities is very frequent.
Opening utilization, with a whole exposition of the cartillages, enabled an exact evaluation of deformities and, as a result, a more precise restoration.
In all of the cases, wrong removals were observed, resulting in the most different types of deformity, ranging from since a small asymmetria until a complete collapse, with total ressection of the cartillages.
After Rethi (4), Sercer (5), Padovan (3) and, most recently, Goodman (1 and 2), Sheen (6), divulgated rhinoplasty through nose openings, we have observed that treatment of the secondary deformities as well as some Address for correspondence: Jorge Ishida ,Rua Padre Pereira de Andrade, 545 IIha do SuI -Ed.IIha Bela, 123/124 Sao Paulo -SP -Brasil -CEP 05480-000 congenital ones, have been extremely improved by this procedure.Incision initially used was the one described by Rethi (4) and, afterwards, we have adopted the one proposed by Goodman (1 and 2), bearing the medium portion of the columella and in a broken line.This procedure resulted, in most of the cases, in a quite invisible scar 3 months ago.
In spite of requiring a longer surgery time, the wide exposition of the anatomic elements, a more symmetrical reparation of the elements is possible.

SURGICAL TECHNIQUE
Incision begins in the marginal portion of both of the wings and is extended till the columella.
Endonasal cutaneous dettachment starts on the point subcutaneous cellular tissue is more flabby con 'nuing' slowly in direction to the columella, where there is a higher adherence of the skin to the cartillage.In this point of surgery, incisions join each other at the medium part of the columella, in the form of a smal inverted "v".
This sequence results in a faster dettachment of skin, avoiding trauma and, sometimes, skin scrubbing at the columella point.Also, it is very important that, in some cases, even being scheduled an open rhinoplasty, deformity can be treated only by ft marginal incision, being not necessary free columella in its entirety.

DIAGNOSIS AND TREATMENT
Sixty-two cases of endonasal deformities were tr~ated ..'Deformities can be classified as follows: 1. Excessive res section 2. Asymmetric ressection 3. Insufficient res section 4. Total res section In 100% of the cases asymmetric ressection was observed, even in the total ones, due to differences in the remaining stump.
Treatments were classified in two groups: 1. Insuficient and asymmetric cases: we tried to free allar cartillages in its entirety, since the medial.crosstill extremety; approaching both cartillages, side by side, a completely symmetrical ressection is possible to be done.2. In the excessive and total ressection cases, we reccur on to grafts of the remaining allar cartillages, septal cartillages or conchal ones.
We frequently obtain leftover fragments from the more lateral portion, that are dissected and sutured to the portion where an excessi ve ressection has been done.Suture is done with monofilar nylon thread 6.0 (Fig. 1  A,B,C and D).
When septal cartillage is chosen,we use fragments of approximately 2.5 x lcm, carved to reproduce the allar cartillage (Fig. 3 A,B,C,D,E,F,G).Carefully, cartillage is divided in its whole espessure.We observe that the 2 sheets obtained present a convexity, rigorously in the same format as the allar cartillages (Fig. 3 A and B).These cartillage sheets are sutured on the remaining cartillage stump (Fig. 3 C,D,F).
In order to get symmetric and, .mainly, the same resistance, stumps must be withered to the same .level,so as the suture graft.This procedure avoids distortion and uneveness of the future endonasal... Conchal graft is obtained through a retroauricuiar incision and wide dettachment of the conchal cartillage.Two convex and symmetric portions are chosen and properly withered.Conchal cartillages, being very thick, need to be carved, mainly in the edges, where they are slender (Fig. 2 A,B,C,D).
In some cases, in order to avoid very large ends, some incisions may be done to decrease the spring resistence.

RESULTS
Endonose was restorated in all of the surgeries performed.Small asymmetry was observed in 2 cases.In one of them, where a simultaneous dorsal grafting was performed, an infection occurred, but was satisfactorily solved by antibioticotherapy.

DISCUSSION
Rhinoplasty with external incision introduced new aspects in the treatment of secondary nose deformations, mainly in what refers to the endonose structural components.Complete view of elements "in situ" enables precise anatomic diagnosis and the large exposition of the surgical area enables surgical procedings, difficult to be performed by the endonasal usual ways.Assessment of losses and cartillage graft on the wings can be done symmetricany.
The three methods applied for the endonasal restoration showed to be very efficient.In small failures, use of small fragments obtained from leftovers of the allar cartillage itself, in terms of results, was the easiest method and the best one, due to the structure and characteristics of this cartillage.
Conchal cartillage, due to higher thickness and less flexibility, even modulable, resulted in a slightly bulbous and firm endonasal.

Figure 1 BFigure 1 C
Figure 1 B -Aspect after endonasal exposition, high asymmetry of the alar cartillages, right alar cartillage seccioned right above domus

Figure 1 D
Figure 1 D -Final aspect of the patient, 6 months after surgery

Figure 3A -
Figure 3A -Fragment of septal cartillage being biparted to obtain cartillage graft for the wing of the nose.The two cartillage sheets show side curve tendency, becoming convexed

Figure 38 -
Figure 38 -Septal cartillage divided in the middle, showing the convex form they acquire