Combining rhinoplasty and endoscopic sinus surgery allows patients to breathe easily, improve their looks, and avoid the time and risk of two operations
Rhinoplasty is one of the most commonly performed aesthetic procedures today. Each year, approximately 150,000 Americans of all ages have “nose jobs.” The goal of the procedure is to improve the appearance of the nose; however, for many patients, nose surgery can also alleviate or cure headaches and breathing problems, correct deformities from birth or injury, and treat chronic sinusitis.
Rhinoplasty and endoscopic sinus surgery, when performed separately, are effective procedures with minimal complication risks.1–7 Combination procedures are performed more frequently today, and may elevate the risks of complications such as infection, bleeding, and edema.8,9 However, a literature review shows that these risks are minimized when elective rhinoplasty in the face of an active infection, extensive sinus pathology, or other systemic illness is avoided.
A review of 52 cases of simultaneous rhinoplasty and endoscopic sinus surgery revealed excellent functional and aesthetic results with no major complications. The benefits of the combined procedures, when they are performed in carefully selected patients, are decreased operative and recovery times, patient convenience, and reduced cost.
Most rhinoplasty candidates are embarrassed by the appearance of their noses and have thought about changing the shape of their noses since their teenage years. Some have deformities from birth or injuries that they want corrected. Many state, “I’ve been told that I have a deviated septum, and I thought you could fix that at the same time.” Conversely, patients who present initially with functional complaints ask, “As long as you’re in there anyway, can you take off the bump and make my nose smaller?”
During a detailed preoperative consultation, the patient’s motivations and medical history are reviewed. We have patients tell us specifically what bothers them about their noses, and ask them to describe their ideal nose to us. If the patient has realistic expectations, his or her facial proportions and aesthetics are documented and computer imaging is performed. The facial anatomy is analyzed for potential cheek or chin augmentation to provide facial harmony.
We then describe our approach to the nose—considering the upper, middle, and lower thirds, and emphasizing conservative, realistic goals with respect to the patient’s overall appearance. If the medical history reveals symptoms of allergic rhinitis and chronic sinusitis—nasal congestion; runny or stuffy nose; white, yellow, or green discharge; pain in the upper jaw or teeth; loss of sense of smell or taste; headache; facial pain; cough; persistent fatigue; or fever—further discussion and workup are necessary.
Starting the Process
Most of the 52 patients in our series complained of nasal obstruction and postnasal drip, followed by facial pain and headaches. Some had a history of asthma or sinobronchial syndrome, with or without aspirin sensitivity.
All patients were treated with medical therapy for at least 3months; this included one or more of the following: multiple trials of antibiotics (amoxicillin–clavulanate, azithromycin, trimethoprim–sulfamethoxazole, fluoroquinolones, or cephalosporins), nasal steroids (beclomethasone, budenoside, flunisolide, or azelastine), decongestants (oxymetazoline or pseudoephedrine), antihistamines (desloratidine, fexofenadine, or loratidine), systemic steroids (methylprednisolone), and allergen-desensitization therapy if necessary. If they failed medical therapy and their sinusitis interfered with their daily activities, they were considered candidates for endoscopic sinus surgery in addition to rhinoplasty.
Nasal endoscopy was performed as part of a complete otorhinolaryngologic examination. The intranasal anatomy was examined first with a fiber-optic headlight and nasal speculum prior to the application of a topical decongestant. The nasal septum, inferior and middle turbinates, and nasal valves were evaluated.
Cotton pads soaked in topical oxymetazoline and xylocaine were then placed along the floor of the nose and in the middle meatus for 5minutes. After appropriate decongestion and anesthesia, rigid 2.7-mm nasal endoscopes (0° and 30°) were used to evaluate the postnasal space, the middle meatus, and the natural maxillary ostia. Any obstruction by septal or nasal pyramid deviations, concha bullosa, or polyposis was noted.
After 4 to 6 weeks of treating the sinonasal disease with medical therapy, computerized tomography (CT) scanning of the sinuses without contrast was performed in the coronal and axial planes. The “sinus protocol” CT limits the cost and radiation exposure, and provides precise information regarding the nasal and sinus anatomy and pathology. Any abnormalities, such as septal deformities, mucoperiosteal thickening, cysts and their specific locations, osteomeatal obstruction, enlarged turbinates, concha bullosa, paradoxical middle turbinates, and adenoidal hypertrophy, were shown to the patient during a second preoperative visit.
The surgical procedures were reviewed again, and this time another family member may have been present. The patients were advised that the concurrent procedures potentially pose increased risks and that either of the procedures may not be performed. All questions were answered and informed consent was obtained. As is the case before all surgical procedures, patients were told to avoid taking blood thinners.
We allowed at least 6 weeks for a sinus infection to resolve prior to the operation. Prophylactic antibiotics were given 1day before the procedure and continued for 1 week. Oral steroids were used preoperatively to shrink swollen mucosa and nasal polyps.
General anesthesia was used in most cases. All patients received 1g of cefazolin or 600mg of clindamycin if they were allergic to penicillin and 6 to 10mg of dexamethasone perioperatively. The nose was anesthetized with 10 to 15mL of 1% lidocaine solution with 1:100,000 epinephrine. Specific injection sites were the nasal septum, dorsum, piriform apertures, and the junction of the middle turbinates with the lateral nasal walls. Often, cotton pads soaked in 1mL of 4% cocaine were placed in the middle meati bilaterally.
Septoplasty was performed through a hemitransfixion incision, and septal cartilage was harvested for later use as potential batten or shield grafts. The inferior turbinates were addressed by outfracture, outfracture with submucosal bipolar cautery, or submucosal resection with a microdebrider. This enlarged the nasal airway dramatically. Then, the middle meatus was examined and the middle turbinate was infractured.
Concha bullosas were treated by lateral resection using a sickle knife and a microdebrider. The uncinate process was taken down using a Cottle elevator and through biting forceps. The natural maxillary ostium was found, and if it was stenotic and polypoid, it was enlarged using backbiters and throughbiters. Any polyps or polypoid tissue was removed from the maxillary sinus.
The ethmoid bulla was opened, and anterior and posterior ethmoidectomies were performed using a ball probe and Blakesley forceps. If the nasofrontal recess or sphenoid was occluded, it was conservatively opened and allowed to drain. Nasal polyps, if present, were removed using a microdebrider.
If there was evidence of extensive swelling, purulence, or excessive bleeding with “angry” mucosa, the rhinoplasty was not performed. The sinuses were then irrigated with normal saline. Packing was seldom used in the middle meatus, but if necessary, we chose absorbable methylcellulose packing to prevent lateralization of the middle turbinate.
The hemitransfixion incision was then converted to a full transfixion incision and connected to bilateral intercartilaginous incisions. The skin soft tissue over the nasal dorsum was elevated, and the bony dorsum was taken down using a double-guarded osteotome and refined with rasps. The cartilaginous dorsum was adjusted with a No.15 blade, and marginal incisions were made to deliver the lower lateral cartilages. The appropriate maneuvers were made to debulk, rotate, and narrow the nasal tip.
Nasal-valve concerns were addressed at this time; spreader grafts were used to support the internal nasal valve after resection of the cartilaginous dorsum. Lateral crural onlay grafts or batten grafts were used to correct external-valve incompetence. Lateral osteotomies were made to narrow the upper third of the nose and close any open roof.
Septocollumellar sutures were used to close the transfixion incision, and a dorsal nasal splint was placed for 5days. External transcolumellar incisions usually were reserved for revision cases. The techniques of the septorhinoplasty or endoscopic sinus surgery were not modified to allow simultaneous procedures.
The postoperative care for the combined procedures was similar to that used if each procedure was performed separately. The patients were transferred in the recovery room and observed for bleeding, airway problems, or visual changes. Whereas bruising from rhinoplasty is usually delayed, intraorbital hematoma from retro-orbital hemorrhage has a rapid onset, usually presents with proptosis, and is a medical emergency.
After the patient was fully awake and had met day-surgery criteria, he or she was discharged and seen the next day to have any packing removed. The nasal cavities were suctioned, and postoperative instructions were reviewed. The nasal splint was removed at day 5, and the nasal cavity was cleaned again. At this time, patients began saline irrigations of the nose; postoperative steroids were used in some patients to reduce swelling.
In contrast with some reports,8 simultaneous functional endoscopic sinus surgery (FESS) did not preclude or limit our postoperative care. Nasal endoscopy with debridement was performed as in FESS alone with no increase in pain experienced by the patient (subjective assessment of the author) or compromise of the aesthetic result.
Rare complications have been described by Friedman, who noted the medial collapse of the lateral nasal wall following concurrent FESS and rhinoplasty, due to resection of agger nasi cells in addition to lateral and medial osteotomies.4 Millman and Smith reported a case of concurrent FESS and rhinoplasty with near-fatal complications.9The patient developed myocarditis, septic shock, and soft-tissue glabellar abscess, presumably from a periosteal breach during osteotomies, allowing direct spread of infection from nasal cavities to facial soft tissues. While rare, these complications warrant vigilance in the postoperative period after any nasal surgery.
Many reports have appeared in the literature about concurrent sinus surgery and rhinoplasty.1–9Simultaneous procedures serve to improve both form and function, to reduce operating and recovery time, and are cost-efficient. This is especially important for patients who want to breathe well and look good, and want the convenience of a single surgery.
Most important to our patients was the opportunity to undergo two operations with one anesthetic, one recovery time, and one period away from work. They were able to resume normal work and social activities within 2 to 3 weeks with minimal morbidity. There were few complications in this series, and patients were satisfied with the outcomes.
Limitations to combined procedures in our series included any condition that resulted in excessive swelling or bleeding and increased the risk of infection. Severe sinus disease—pansinusitis, acute infection, or panpolyposis—increases morbidity as a result of more extensive surgery, prolonged operative time, and increased intraoperative edema and bleeding. Aesthetic concerns were complex rhinoplasties and additional procedures that lengthened operative time, such as blepharoplasty or facial rejuvenation.
In our series, patients with pansinusitis–panpolyposis or those who needed complex revision rhinoplasty did not undergo concurrent procedures. A few patients with limited sinus disease and multiple facial-rejuvenative procedures did undergo the combined procedures without postoperative sequelae.
Despite concerns about the spread of infection from the sinuses to the nasal tissues, concurrent rhinoplasty and endoscopic sinus surgery may be performed safely with minimal risks. Proper patient selection and sound intraoperative judgment can avoid potential complications.
Ramtin R. Kassir, MD, FACS, is a double board-certified facial plastic surgeon and otolaryngologist and director of the Mona Lisa Cosmetic Surgery Center in Wayne, NJ, and Dallas. He is also the chairman of the Department of Otolaryngology at St Joseph’s Wayne Hospital. He can be reached at (973) 692-9300 or via his Web site, www.doctorkassir.com.
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