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K-Area Preservation in Primary Rhinoplasty
The principle of conservative rhinoplasty, called “preservation rhinoplasty” by Daniel, is to improve the shape of the nose while preserving its main anatomic structures, especially the osseocartilaginous vault, and protecting or, even better, improving its main function of ventilation. It is better to lower the dorsum of the nose than to resect it, then to reorient the cartilaginous arch by reshaping the junction between the nasal bones and the septotriangular cartilage at the level of the K-area modified in a semimobile joint by a previous septoplasty. Preservation rhinoplasty primarily targets reduction rhinoplasty. Preservation rhinoplasty is not limited to the nasal dorsum; preserving the ligaments and remodeling the alar cartilages using a subperichondrial dissection is also a philosophy of this technique.
Introduction
What are the different elements in the history of primary rhinoplasty? Why does preservation rhinoplasty experience so much international support today?
In rhinoplasty, there are three different philosophies. The most known and practiced follows Joseph, whose principle is to remove deformities, in particular the osseocartilaginous hump, using an endonasal approach. The second philosophy, more fashionable nowadays, is structural rhinoplasty, which became popular in the 1990s, following the popularization of the external transcolumellar approach. The third philosophy, described by Goodale, preserves the nasal arches, which provide the function and aesthetics of the dorsum: the principle is to reduce the base of the bony pyramid and to lower it while reshaping its appearance. In the group of conservative rhinoplasties, Cottle developed a concept of monobloc septoplasty together with upper lateral cartilages (ULC), and called the junction between the nasal bones and the upper lateral cartilages the “K-stone area”.
What is the difference between the Cottle septorhinoplasty and Goodale rhinoplasty? Both procedures lower the dorsum “en bloc” by creating an empty space under the osseocartilaginous arches. Goodale suggested a high resection of the septum under the nasal dorsum: the septum, which is the central pillar of the nasal pyramid, is approached through its upper part only. Cottle suggested a complete repositioning of the whole septum and ULC; the sagittal anterior rotation of the septum is performed around the axis of the “K” zone, which is lowered at the same time. This requires complete disarticulation of the cartilaginous nose from the bony nose, except where the bones overlap the triangular vault, as the first step. The Cottle technique has undeniable indications and it is still used by some teams around the world; for example, in Mexico (Lopez Infante then Lopez Ulloa), in Brazil (Ishida, Dewes, Ferraz), and in Europe, where it has returned to fashion under the impetus of Finocchi followed by some “preservers.” In France, Guillen and Wayoff were the pioneers of the “Cottle,” followed by Jankowski who modified the technique.
Preservation rhinoplasty, as described by Goodale, is experiencing a resurgence because of several factors. The main reason is the increasing complexity, perceived as exaggerated by many surgeons, of the structural rhinoplasty that has been in fashion since the 1990s, whereof congresses and courses have proliferated across the world to the point of it becoming the technique of reference in modern rhinoplasty. The issue is the precise restructuring of the cartilaginous vault; this procedure requires that multiple grafts be harvested from the septum in an effort to create a strong skeleton. Although the structuring technique often has good results when performed by experts, its complications may lead to secondary repairs that require harvesting additional cartilage grafts, most often from the rib, and operations that may last longer than 5 hours. Such surgeries are not necessarily guaranteed to be more successful, or to have better results, than less complex alternative techniques, which are less traumatic to the patient, can be completed more quickly, and result in shorter healing times. Perceived as excessive or even dangerous, structural rhinoplasty is being abandoned in primary rhinoplasty by inexperienced surgeons. However, it has allowed for the development of new concepts for grafts and reconstructions, which has been especially influenced by the widely used external approach. It is significant to note that Rollin Daniel, a pioneer of structural rhinoplasty (to which he brilliantly contributed with his technical innovations and his books), switched to preservation rhinoplasty, as he has completely changed his opinion. He is now one of three leaders, with Saban and Çakir, teaching primary “Preservation Rhinoplasty.”
The preservation technique is also gaining popularity because of events in the United States. The discontinuation of “functional septorhinoplasty” in the 1970s was not related to complications or unsatisfactory outcomes, but rather to political and technical issues. Political, because Cottle was a central figure in rhinoplasty in the United States during the 1960s, where he promoted his technique in courses and congresses. His relationship problems in American rhinoplasty societies, details of which are off-topic here, led to the burying of Cottle and his philosophy under a lead cap. Technical, because the difficulty of teaching the Cottle method, which used a closed approach and was based on a rather complex septoplasty, made its practice very limited. In addition, the Cottle method is not suitable to all clinical situations, leaving the field open to other techniques.
The modification of the conservative philosophy comes from Saban et al., who followed Gola in the tradition of Goodale. Outcomes related to Joseph’s technique, especially abnormalities of the dorsum (open roof, inverted V, asymmetries, irregularities of the dorsum and saddles) and the difficulties that occur in structural rhinoplasty, do not occur during conservative rhinoplasties. In addition, the approach to the septum is greatly simplified, and can be mastered by any nose surgeon. The technique can be performed open or closed and the use of video endoscopy facilitates practice and teaching. The current proliferation of courses and congresses that deal with the theme of preservation rhinoplasty, including in the US bastion of structural rhinoplasty done through open approach, accounts for the shift in attitudes and the importance of this conservative philosophy.
However, we must not confuse the approach and the philosophy of rhinoplasty. The approaches to rhinoplasty, whether open transcolumellar or closed endonasal, are only technical means to expose the anatomical structures of the nose. The approach is the choice of the surgeon, based on their experience, the anatomical needs of the patient, and the needs for teaching. For simplicity, there are three philosophies (resection according to Joseph, preservation according to Goodale or Cottle, structural according to Toriumi) and two surgical approaches (endonasal and transcolumellar). However, philosophy can also determine approach. Çakir describes the preservation of the ligaments of the nose using a subperichondrial endonasal approach.
New technical means have been developed to promote visualization and teaching (videos, endoscopes) or bone remodeling and osteotomies (ultrasound or Piezo), leading to the concept of rhinosculpture. The combination of preservation rhinoplasty and the external approach with the use of Piezo-instruments has been widely popularized by Göksel, leading to the concept of “precision rhinoplasty.” There is no doubt that with its dynamism and inventiveness, Turkey is currently the world leader in rhinoplasty.
A Few Words of the History of Preservation Rhinoplasty With High Septal Resection
After the initial description by Goodale, Lothrop published an article on a new instrument he developed for this conservative technique, without mentioning Goodale in his bibliography. In France, Sebileau, Dufourmentel, Maurel, and Gola are the main names that we know who applied this philosophy to their rhinoplasties. More recently, Saban gives pride of place to the preservation of the dorsum and, above all, contributes to popularizing it internationally, especially in Europe, Turkey, Brazil, Russia, and the United States. Daniel, coauthor of the article “The push-down reassessed,” published an editorial in the Aesthetic Surgery Journal, entitled “Preservation rhinoplasty, the 3rd rhinoplasty revolution,” which served as a detonator at the global level. The first international congress, The Joint Congress of the European Academy of Facial Plastic Surgery and the Brazilian Academy of Surgery of the Face, was organized in Nice, France, in 2019 on this theme, after the one run in Istanbul in 2018 by Çakir and brought together all surgeons practicing conservative rhinoplasty around the world for the first time, with 70 speakers from 47 different countries, witnessing the revival of this philosophy. Finally, in 2018, Çakir et al. published Preservation Rhinoplasty , a book with the main purpose of specifying the technical aspects and teaching preservation rhinoplasty.
Principles and Concepts
Important Reminders of Surgical Anatomy: Understanding Operative Biomechanics
For surgeons, it is worth remembering that the nose consists not only of bones and cartilage but also soft tissues, including the skin covering and the perichondral–periosteal sheath, all of which play a key role in the concept of nose reshaping.
Often interpreted as three different cartilages, the two triangular ULC and the septal quadrangular cartilage represent a single septotriangular structure, forming the cartilaginous arch of the middle third of the nose, and ensuring the shape, aesthetics, and respiratory function of the internal valve ( Fig. 53.1 ). Jankowski linked it directly to the embryonic nasal olfactory membrane. These cartilages extend under the bones of the nose (bony segment; called “bony cap” by Daniel) and this overlap is called zone “K.” The central K-area (CKA) and the lateral K-area (LKA) are distinguished. The CKA corresponds to the septum and often goes upward toward the radix, especially in children; the LKA corresponds to the cephalic extensions of the ULC with a triangular shape and stops lateral to the suture of the nasal bones with the frontal processes of the maxilla. The ULCs are attached laterally to fibrous membranous triangles and more distantly to pyriform ligaments. The osseocartilaginous overlap of zone K is thus a fixed three-dimensional (3-D) structure that forms a T-shaped aspect. To make it flexible, it is necessary either to disarticulate the bones from the cartilages, or to remove the underlying septal pillar, which plays the role of a stiffener in the manner of a coat-hanger (“coat-hanger effect”). In the preservation technique, this high septal resection, sometimes associated with LKA disarticulation and/or that of the pyriform ligaments, makes it possible to transform a 3-D structure into a semi-mobile 2-D structure that is flexible. The profile line can thus be lowered and/or curved to modify the shape of the nose by making it concave if necessary, especially in women. The dorsal lines are respected, and the morphology of the nose is perfectly natural both visually and at palpation.
The nasal septum is a composite structure ( Fig. 53.2 ), formed by the quadrangular cartilage articulated to four bones; the nasal bones superiorly, the ethmoid superoposteriorly, the vomer inferoposteriorly, and the maxillary caudally. Recently, East and Saban (2019) conducted a cone-beam study of about 100 patients evaluating the area of attachment of the perpendicular plate of the ethmoid under the nasofrontal junction. The average distance between the anterior ethmoidal angle and the cribriform plate is greater than 2 cm; the most anterior point is relatively high in childhood and then “goes forward” with age, because of an anterograde process of ossification and growth. Thus, the dorsal septum is generally only cartilaginous in adolescents. In surgical practice, the dorsal resection of the septum must be carried out under the nasofrontal junction, but must not extend beyond it; sometimes, this resection is strictly cartilaginous when the septal cartilage rises very high under the nasofrontal junction.
The bony cap corresponds to the part of the nasal bones covering the ULCs. The preservation of this bony hump is not a surgical or functional requirement. In many clinical situations, surgeons rasp or even systematically resect it, which both reduces the risk of postoperative recurrence of the bony hump and mobilizes the K-area more easily, particularly in order to curve it. This reduction of the bony cap does not influence the stability of the dorsal lines and does not expose the nose to the risk of an open roof deformity if the continuity of the cephalic extensions that form the new roof of the ULCs is preserved.
Push-Down or Let-Down?
The frontal processes of the maxillae form the bony bases that connect the nasal pyramid to the face. Their section/resection is mandatory to allow the mobilization of the nasal pyramid. In addition, these bony processes are sheathed in a resistant periosteum whose prior separation allows a greater mobilization when it is necessary: bilateral detachment and lowering of more than 6 to 8 mm from the profile line, or asymmetrical detachment in the case of a deviated nose. Resection (wedge resection) was introduced by Huizing in the Cottle procedure, creating the let-down, which is simply a technical variant of the push-down.
The choice of surgical approach is important with regard to the soft tissues and ligaments of the nose. The ligaments of the nose correspond to the superficial and deep extensions of the nasal superficial musculoaponeurotic system (SMAS). It has been proven (Çakir, Neves, Palhazi, Daniel) that the ligaments support the tip. They separate the nose into compartments. Respecting them makes it possible to reduce dead spaces, to limit postoperative swelling, and to better control the healing dynamics. The endonasal interseptum–columella approach allows infra- and retro-ligament access, if not extended laterally into an intercartilaginous incision (Saban). The external approach often requires dissection or disinsertion of these ligaments in order to get upward access. Finally, these expansions can be used to cover the lower lateral cartilage (LLC) in thin-skinned patients (Zholtikov, Cobo). More rarely, in thick-skinned patients, ligaments can be responsible for filling the supratip and require careful excision (Pitanguy). Çakir recommended the protection of these structures by subperichondrial dissection, and their reinsertion at the end of surgery.
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