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Management of the Keel Nose and Associated Valve Collapse
Fred J. Stucker, MD;
Timothy Lian, MD;
Matthew Karen, MD
Arch Otolaryngol Head Neck Surg. 2002;128:842-846.
ABSTRACT
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Objectives To analyze the anatomical abnormality of the keel nose and correlate
the findings with etiologic maneuvers of a routine rhinoplasty procedure;
to identify the contributing factors and offer suggestions to avoid or decrease
the severity of these surgical complications; and to present an effective
revisional procedure to correct the functional and cosmetic consequences of
this deformity.
Patients and Methods A total of 47 patients (31 women and 16 men; age range, 18-71 years)
with a keel-appearing nose presented for revision rhinoplasty. All had undergone
at least 1 rhinoplasty procedure, and 39 had undergone 2 or more previous
nasal procedures. All patients had bilateral lateral nasal wall collapse and
an associated severely compromised internal nasal valve. All patients underwent
reconstruction with a conchal cartilage overlay graft.
Results All patients had a moderate to excellent cosmetic improvement; the subjective
improvement in nasal airway was more dramatic. Since patients with a keel
nose have an associated internal valve collapse, both abnormalities are addressed
simultaneously with the conchal cartilage overlay repair, which results in
minimal morbidity with no major complications.
Conclusions Conchal cartilage overlay repair uses a cartilage graft from the auricle
with a recommended external rhinoplasty for placement. Appropriate sizing
and fashioning precede the precise placement and suture fixation. This technique
addresses both functional and cosmetic abnormalities.
INTRODUCTION
THERE IS A STRONG likelihood that a procedure as complicated as a rhinoplasty
will result in some unintended consequences.1-3
To achieve the desired goals in rhinoplasty, there is usually an elaborate
sequence of incisions, excisions, and version techniques, with deliberate
and sometimes unintended consequences, which promote the art of defensive
surgery. Perhaps the greatest stride in defensive surgical treatment is the
generally accepted tenet of tissue preservation as opposed to the once common
practice of more radical tissue resection in rhinoplasty. Realizing and optimizing
the goals of surgery as well as eliminating or minimizing the unintended outcomes
should be the focus of all surgeons who are engaged in rhinoplasty surgery.
This article addresses an aspect of this philosophy.
Surgeons have retrospectively evaluated their long-term rhinoplasty
outcomes only over the past 1 or 2 decades. This follow-up has allowed scrutiny
of the consequences of surgical actions. In the 1970s, it was routine to present
6- to 12-month postoperative results with a rather smug self-assurance of
success. It is our experience, however, that time itself is the real enemy
of the rhinoplasty surgeon. With the exception of some cases of cleft lip
rhinoplasty, where the skin memory of the deformity gradually diminishes,
the passage of time amplifies surgical imperfections in patients who have
undergone rhinoplasty. This is certainly true in cases involving keel nose
or midnasal collapse.
PATIENTS AND METHODS
The preoperative photos of all patients who underwent a secondary rhinoplasty
procedure performed by the senior author (F.J.S.) since 1982 were reviewed,
and 47 were categorized as demonstrating a keel nose deformity. We define
keel nose as an extremely narrow nose with an inordinately acute angle of
the upper lateral cartilages as they meet the quadrangular septum. This keel
defect often extends cephalically and includes the bony pyramid. As time passes,
the upper lateral cartilages drift inferiorly as a result of their resection
from the septum. This deformity is more likely caused, or at least compounded,
by severing of endonasal mucosa. As the upper lateral leafs retract inferiorly,
the septum often appears in relief as a keel (Figure 1). A profound functional inspiratory collapse of the flail
lateral sidewalls occurs in association with keel nose deformities. Therefore,
the correction must address both the functional collapse and the keel nose
cosmetic deformity.
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Figure 1. Representative patients with a
keel nose deformity.
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Our series included 47 patients (31 women and 16 men; age range, 18-71
years). Conchal cartilage overlay grafts were used to correct the keel nose
deformity in all cases.
We routinely use the external approach, but on occasion we have used
an endonasal technique. The latter is actually more time consuming because
of the difficulty in accurate graft placement in the absence of direct visualization.
The conchal cartilage graft can be harvested from either ear. The skin flap
is elevated, with an incision just medial to the crus of the antihelix. The
incision is carried out anteriorly medial to the inferior crus and inferiorly
to the roll of the antitragus. The skin flap is attached and hinged anteriorly
at the external meatus, and the entire conchal cartilage is removed. The skin
flap contains the perichondrium; the posterior perichondrium is firmly adherent
to the cartilage and stays with the graft. As the patients age, the auricular
cartilage calcifies. Care in harvesting is therefore advised with elderly
patients. It is quite easy to break and lose the necessary graft continuity
if one is not careful. The concha is first shaped with a knife (Figure 2) and further contoured with a diamond fraise. The cartilage
is abraded on the surface, which is devoid of attached perichondrium. The
graft is sized by placing it over the midnasal deformity. It is designed to
replace the supraseptal integrity of the upper lateral cartilages, which have
lost their lateral support. The graft must be positioned cephalic to the lower
lateral cartilage (Figure 3). On
occasion, resected lower lateral cartilages must be reconstructed, which can
be done with septal or additional auricular cartilage. Once the graft is appropriately
fashioned and sized, the septum is resected as necessary to the desired level.
At this point, we usually place a fixation suture to stabilize the graft.
The external rhinoplasty skin flap is repositioned, and 1 to 2 percutaneous
mattress sutures are placed on each side of the nose to ensure proper stabilization
and to coapt the skin and endonasal lining to the graft and upper lateral
cartilage remnant. The mattress sutures prevent blood and/or fluid accumulation,
which could slow healing, cause an infection, decrease assimilation of the
graft, result in thickened lateral walls, or perhaps even cause resorption
of the graft.
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Figure 2. Sculpturing the conchal cartilage
with a No. 15 blade. The graft is further refined with a diamond fraise.
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Figure 3. Diagram demonstrating conchal
graft placement.
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The first and most important mattress suture is oriented vertically
inside the nose and horizontally outside the nose. The vertical orientation
snugs the endonasal lining into the apex of the valve, hopefully recreating
a properly functioning nasal valve. The cutaneous part of the mattress sutures
is oriented horizontally or parallel to the relaxed skin tension lines for
cosmetic considerations. The sutures are tied over a Freer elevator and thus
are loose enough to accommodate the expected tissue swelling. There is no
intranasal packing or dressing. A routine external dressing of paper tape
and plaster casting material is used. The cast is removed in 5 days, and the
mattress sutures are removed 1 week later. Very rarely, swelling may be excessive
and the sutures can burrow into the skin, necessitating early removal of the
sutures. This complication occurred in 2 of the cases in our series.
RESULTS
All of our patients benefited, to varying degrees, both cosmetically
and functionally. There was subjective improvement in nasal breathing in all
patients. One patient required dermabrasion at the mattress suture sites,
where swelling had buried the suture in the skin. There was a good deal of
inflammation when the sutures were removed prematurely on day 5.
Because we did not identify any patients with the keel nose deformity
who did not have collapse in the valve area, the correction must address both
concerns. Keel deformities are only one of the situations in which valve abnormalities
occur.
A few patients do not consider the excessively narrow nose a cosmetic
problem. Intrinsic to our recommended correction is a postoperatively broader
nose. Although the patients may have preferred the narrower nose, the improved
nasal function has resulted in satisfaction in all cases. Two patients in
this study required a second procedure for what we consider a less-than-precise
technical execution. In both cases, there was a failure to size the lateral
extent of the graft, which caused a slight bowing. This complication could
have been avoided by trimming the graft or developing a more adequate superolateral
pocket.
COMMENT
It is clear that the keel nose deformity with lateral wall collapse
is the consequence of surgery, and it is equally clear that the functional
component is aggravated by time and aging. There are numerous approaches to
correcting valve problems,4-7
but in our experience they fail to improve both the functional and the cosmetic
keel nose abnormality. The popular use of spreader grafts,8-9
which may improve the narrow appearance, has little long-term effect on improving
nasal function other than minor valve problems. Correcting the cosmetic keel
nose abnormality without addressing the functional valve collapse fails to
provide optimum treatment. Our recommended correction of the nasal airway
difficulty has the added benefit of addressing the keel nose cosmetic deformity.
The most common and consistent predisposing factors in a majority of
the cases in our series are previous rhinoplasty procedures (2 or more), significant
hump removal at the first procedure, relatively short bony-to-cartilage ratio
in the nasal vault, periosteal tunnels developed prior to lateral osteotomies,
and severing of endonasal mucosa with resection of the upper lateral cartilages
from the septum. Another predisposing condition occurs when the primary procedure
is performed endonasally (Figure 4). Our recommended method of correction uses a properly sized conchal cartilage
graft placed between the remaining cartilaginous midnasal structural vault
and the elevated skin flap.10 This properly
shaped and fashioned conchal cartilage graft is remarkably like an intact
bilateral upper lateral cartilage (Figure
5). The septal cartilage, which is the keel portion of the deformity,
must often be brought down to accommodate the increased height of the dorsum,
which is caused by the conchal graft. This correction results in a more appropriately
shaped nose.
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Figure 4. Diagram showing rhinoplasty incisions
and osteotomies demonstrating a compromised blood supply and the potential
for upper lateral cartilage resorption.
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Figure 5. Conchal cartilage resembles the
upper lateral cartilages structurally intact in midline.
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The integrity of the lateral support of the upper lateral cartilage
is essential to create a valve angle that is sufficient for a normal airway.
Severing the upper laterals from the cartilaginous septum often destroys the
rigid integrity required to maintain a valve angle that is sufficient for
a patent nasal airway. Spreader grafts lateralize the upper lateral cartilage
2 to 3 mm (the width of the graft placed), but do little to change the flaccidity
of the lateral nasal wall. Inspiration creates a relative vacuum intranasally,
which continues to collapse the nasal wall, in spite of the 2- to 3-mm lateralization
of the upper lateral cartilage. Our experience with spreader grafts is that
minor to moderate keel nose deformities can be improved markedly in appearance
but that any significant airway improvement is rather rare. The flail lateral
nasal walls are not significantly changed functionally with a cartilage shim
at the angle. It is our contention that to consistently reconstruct the valve
angle and support the upper lateral cartilage, structural support is required
over the septum. To address both the functional flail lateral nasal sidewalls
and the inordinately narrow (keel) nose, we recommend the placement of a conchal
cartilage overlay graft (Figure 6
and Figure 7).
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Figure 6. A, Preoperative frontal view of
a patient who underwent 3 previous rhinoplasties. This patient has total nasal
collapse on nasal inspiration. B, Frontal view of the patient 2 years after
he underwent the described technique. He has a normal nasal airway. C, Preoperative
right lateral view. D, Right lateral view 2 years after surgery.
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Figure 7. A, Preoperative view of a patient
who underwent 2 prior rhinoplasties. Both subjective and objective (rhinomenometry)
nasal obstruction were noted. B, Postoperative frontal view of the patient
2 years after conchal cartilage reconstruction of upper lateral cartilages.
He has a normal subjective nasal airway postoperatively and a patent nasal
airway on rhinomenometry.
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CONCLUSIONS
To repair the keel nose deformity, conchal cartilage is harvested and
fashioned so that it mimics the intact upper lateral cartilages. Our recommended
surgical intent is to recreate the integrity of the preoperative anatomy.
The cartilage is shaped first with a No. 15 blade and completed with
a diamond fraise wheel abrasion. This procedure permits the perichondrium
attached to the posterior aspect of the graft to remain intact, thus optimizing
the rapid assimilation of the cartilage graft. By thinning the periphery of
the graft, the likelihood of a visible or palpable ridge is greatly minimized.
Reconstructing the graft is an important step, as it recreates the upper
lateral cartilage. It must be placed cephalic to the lower lateral cartilage.
We use 2 to 4 percutaneous mattress sutures not only to firmly fix the graft
in place, but also to coapt the tissues. This precludes a lamina of blood
accumulation above the graft, which could lead to resorption of the cartilage
or thickening of the lateral nasal wall. These sutures are routinely removed
approximately 10 days after surgery. The technique described herein is effective
in correcting the 2 major problems of cosmetic and airway obstruction. We
have used this technique in 47 patients, with excellent results.
AUTHOR INFORMATION
Accepted for publication December 17, 2001.
Corresponding author and reprints: Fred J. Stucker, MD, Department
of Otolaryngology–Head and Neck Surgery, Louisiana State University
Health Sciences Center, 1501 Kings Hwy, Room 33932, Shreveport, LA 71103-4209.
From the Department of Otolaryngology–Head and Neck Surgery,
Louisiana State University Health Sciences Center, Shreveport.
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ABSTRACT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
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Khosh et al.
Arch Facial Plast Surg 2004;6:167-171.
ABSTRACT
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