Monday, April 14, 2014

Innervation of the nasal septum and lateral wall

As I have already mentioned in past blog postings I ended up with severe chronic neuropathic pain after my failed nose revision surgery in 2005 .  What's interesting is that most rhinoplasty surgeons don't educate us lay people (patients) about the risk and complications that can arise from nerve injury during rhinoplasty. In fact not only are some rhinoplasty surgeons "apparently" at a loss about my complication, one reconstructive rhinoplasty surgeon mentioned to me during the consult that there are no nerves in area of where my pain is, which happens to be the lower third of my nose ( tip lobe area including columella). Really? Well a very quick search & scant amount of reading on the internet can easily debunk that tale. However if my memory serves me right he was the first one to suggest my nerve pain may be due to Traumatic Neuroma *1. Perhaps he meant there are no main nerve branches in the tip region where my pain seems to originate from. Anyway lets now turn our attention to the nerves within the human nose.

The upper most yellow region is: Olfactory bulb, & nerves
Surgical Anatomy of the nose by Natalie P Steele and J Regan Thomas (Ch.1 Rhinology and Facial Plastic Surgery Fred J Strucker & assoc. ) 

Nerve supply to the nose is externally derived from branches of the trigeminal nerve. The skin of the nose superiorly at the radix and rhinion is supplied from branches of the supratrochlear termination of the ophthalmic nerve. The anterior ethmoidal nerve, another branch of the ophthalmic, may traverse the dorsum of the nose to supply the tip [12]. In endonasal or in open rhinoplasty, this nerve bundle may be damaged by over-aggressive endonasal incisions violating the fibromuscular layer, or elevation of the S-STE (skin-soft tissue envelope) in the wrong plane, resulting in a numb nasal tip. The infraorbital nerve may also contribute branches to the lateral nasal walls, columella, and vestibule. Knowledge of this external nerve supply is necessary to perform adequate nerve blocks for closed reductions, or for rhinoplasty under local anesthesia with sedation. Intranasal anesthesia is also a prerequisite for these procedures. This may be performed with intranasal cocaine pledgets or other strategically placed topical anesthetics. Perhaps the most important target is the sphenopalatine ganglion located in the posterior portion of the nose just posterior to the middle turbinate. Internal branches of the anterior ethmoid must also be anesthetized in the superior portion of the nose to complete a total nasal block.  

Nasal skin is innervated by the infratrochlear and external nasal branches of the nasociliary nerve, and by the nasal branch of the infraorbital nerve.

 Olfactory Nerve (N I)    
The olfactory nerve is a special sensory cranial nerve that is responsible for the sense of smell. The receptors of these neurons are found in the olfactory epithelium and the axons pass through the cribriform plate of the ethmoid bone. These neurons synapse within the olfactory bulb which lies directly above the cribriform plate.

Interesting Observation To Note.  
I have been corresponding with someone who also developed nerve related pain and discomfort after revision rhinoplasty a few years ago.  The person also had the open approach technique repeated along same previous surgical incision, as was done with my nose.  This raises suspicion as to whether repeating the open approach technique along same scarred incision increases chances of developing neuropathic pain or neuroma's due to nerve trauma along skin tissue. Another possibility for explaining nerve pain or neuroma's is large removal of scar tissue along the columella /tip region resulting in a lot of new scar tissue development during healing period which may entrap nerve tissue. The open approach has become very popularized to the point that very few rhinoplasty surgeons are performing the more complicated but less invasive closed approach technique which has it's advantages as well as some disadvantages. So with more rhinoplasty surgeons performing primary and revision rhinoplasty with the open approach we may see a rise in unexpected complications due to trauma such as nerve trauma.

*1 Traumatic neuroma follows different forms of nerve injury (often as a result of surgery). They occur at the end of injured nerve fibres as a form of ineffective, unregulated nerve regeneration; it occurs most commonly near a scar, either superficially (skin, subcutaneous fat) or deep (e.g., after a cholecystectomy). They are often very painful. Synonyms include scar neuroma, amputation neuroma, or pseudoneuroma.,d.aWc

Friday, March 14, 2014

Why revision rhinoplasty surgeons should ask to see pictures of future patients unoperated fully developed nose

When a new revision patient visits a rhinoplasty revision surgeon for a consult the surgeon has no idea how much work was done prior in the reduction of the size of the patients original nose unless patient presents them with pictures of their un-operated fully developed nose. The patient may of presented their operative report at time of consult to the revision rhinoplasty surgeon however it still leaves the surgeon guessing & imagining what the nose looked like prior to the previous/original surgery.  I believe this is a critical error that could easily be rectified by new patients presenting the revision surgeon with images of their original [innate] fully developed nose. If you have had multiple surgery's I believe it would be beneficial as well to present the revision surgeon with all the before/after pictures the previous surgeon's took of your nose. The reason I feel so strongly about this is based on my own personal experience. When you have a very large natural nose and end up having a number of revision surgery's by surgeons who 'blindly' and unwisely keep reducing the size of it, this may lead to serious irreversible consequences.

 Example: The last revision surgeon i went to  wasn't very experienced or knowledgeable in complicated revision surgery and reduced my already surgically reduced tip. It was angled slightly too far upwards and was over projected. It wasn't in line with the bridge of my nose which was over-resected from previous surgery's. From previous surgery's I had my tip reduced/repositioned twice. I had made him aware of this and brought him my O.R's and my before/after from my previous surgery, but no pictures of my original un-operated fully developed nose. I had a consult with another revision surgeon before this last inexperienced surgeon operated on me, and his opinion in regards to how to correct my disproportionate tip/bridge profile  problem would of been the correct and safer approach. Let's refer to this experienced revision surgeon as Dr. C. and my last inexperienced surgeon as Dr. S. Dr. C.'s approach was to not reduce my tip but to increase the projection of my bridge (known as dorsal augmentation) thereby  bringing it in line with my tip by adding *1 rib cartilage. The estimated time of surgery was between 4 to 6 hours. Dr.S. told me he could prevent me from going through the pain of having rib cartilage and use some ear cartilage (however not in my bridge) but for collapsing nasal valves' which he ended up not doing, and he could 'bring down' my tip and do surgery all within 1and 1/2 hours.  I should of asked Dr. S. what he meant by 'bringing down ' my tip because I was under the impression he would simply rotate it downwards possibly with sutures instead of removing more of my lower lateral/medial cartilages which was already deficient, and remove what he considered heavy scar tissue all along my columella. In the end my tip was reduced and not as out of proportion with my bridge. Small consolation considering the grave consequences I ended up with. Cosmetically my profile looks short/weak for a male; structurally the tip is somewhat collapsed due to the accumulated effect of over re-sectioning of the supporting tip cartilages and *2 physiologically; I ended up with permanent painful neuropathy with associated side effects of allodynia/ hyperesthesia. 
Fig.1  Profile: Disproportionate tip to bridge ratio

Now whether presenting Dr.S. with pictures of my original sized un-operated nose would of changed his mind of doing another tip reduction like he did is unfortunately left to hindsight. To be clear Dr.S. just as previous surgeons including Dr.C. never requested or had such a picture of me. Considering Dr.S. had all my operative reports however he would of seen I had two prior tip reductions which should of been a red flag for doing another one especially when a different but more complicated approach would of achieved the desired results.  He also was aware I had two prior inferior turbinectomy's but that didn't stop him in doing another one in both nostrils, which he made a condition for going ahead with the surgery.  So in all probability presenting original pictures of my nose to Dr.S. would not of made the slightest of difference. But not all surgeons think alike. Each one is an individual who has their own beliefs, thoughts, idea's, aside from their education, preferred surgical methods and experience. The more information you can supply your future revision surgeon with the better informed he/she will be, presuming they take the time to study your past history. So I would still recommend strongly for a revision patient to dig up some old photo's of your un-operated fully developed nose and present it to your future revision surgeon making him aware of all the transformations which have already taken place. 

It's important to understand that your original un-operated fully developed nose contains/contained within it a proportionately developed network of nerve endings, vascular system, turbinate bone and tissue. Over re-sectioning of any specific area containing the aforementioned anatomy can lead to a breaking point where one can end up with serious consequences.

This hopefully will make your next revision nose surgeon think twice as to which surgical approach he/she will take with you and deter him/her from doing another reduction or aggressive reduction on your tip (as was done on me) * where you end up with similar disastrous results.

*1 The reason rib graft was recommended was because I didn't have sufficient septal cartilage to spare.

*2 Even though I developed painful neuropathy in the lower part of my nose after my surgery in 2005 the exact cause of my neuropathy is undetermined. This is because Dr.S. also over-resected my inferior turbinates which links to the trigeminal nerves. However i have my doubts that the origin of pain is related to the turbinates since many people who have had their inferior turbinates removed do not complain of nerve pain. 

*3 SEE

Tuesday, July 23, 2013

Deviated Septum vs Crooked Nose

All crooked/twisted noses have an underlying septal deformity that requires correction and reconstruction to achieve and maintain a long term straightening of the deviated septum.  It is not uncommon for both septal  and pyramid deviations to be corrected at the same time A deviated septum  is corrected by having a septoplasty to improve breathing. This is normally addressed by  correcting the abnormal curvature of the nasal wall consisting of the septal cartilage (the quadrangular cartilage) and bones at back (vomer and ethmoid bone).  This can be done with a closed (endonasal) approach. A localized deviation or spur is purely a functional problem and has no translation to the external shape of the nose.  A crooked/twisted nose usually involves more then just surgical repair or partial removal of the inner quadrangular septal cartilage . Having a septoplasty alone does not mean you will see a external physical change regarding the asymmetry of your nose. A crooked/twisted nose could involve many or all components of the nose cartilage and bone structures from the top/down (cephalic/caudal) region of the nose this would involve anything from the bony pyramid (upper third of your nose) all the way down to the caudal septum (deviation in this region is known as having a caudal deflection), nasal spine & maxillary crest. From the front/back (anterior/posterior) region of the nose this would involve anything from the side of the bridge (medial section of the bony pyramid) of the nose to the most lateral aspect of the nasal bones, or to where the quadrangular cartilage adjoins to the maxillary crest, nasal spine, vomer and perpendicular plate of the ethmoid bone. Sometimes the aforementioned bones need to be corrected to assist with aligning the nasal wall. . The pair of upper lateral and lower lateral cartilage, and medial cartilage are usually evaluated and those which are found asymmetrical after all other corrections to the septum has been made will be modified in this type of surgery. Technically this is referred to as having a septorhinoplasty because there will be a visible cosmetic change to the external shape of your nose.

Pietro Palma M.D. and Paolo Castelnuovo M.D.Chapter 29 p. 320 Correcting the crooked nose from textbook Advanced therapy in Facial Plastic & Reconstructive surgery edited by T. Regan Thomas M.D

Authors classify crooked noses in three basic variations. However, it is important to realize that any of these three categories may be found in various combinations with each other.

Type 1: Single Opposing Convexity/Concavity

The C-shaped and inverted C-shaped noses represent the paradigmatic expression of type 1 deformity. The midnose is invariably involved. Tip-definition point and nasion can be correctly located on the midline axis.

Type 2: Double Opposing Convexity/Concavity

Type 2 crooked nose includes S-shaped and inverted S-shaped. The three framework arches (bony vault, cartilaginous dorsum, and inferior nasal third ) are the most frequently involved with variable combinations of convexity/concavity. Interdomal midpoint and midline rhinion are often out of the midsagittal axis.

Type 3: Laterally Deviated Noses

The typical laterally deviated nose appears straight in terms of alignment of the nasal structures but presents different heights of the two halves. The interdomal midpoint is invariably displaced off center of the midline axis. The angulation may start at the nasion or the rhinion. When the angulation is located at the nasion the halves of all three nasal arches present different heights. Angulation starting at the rhinion implies a straight or near-straight bony pyramid.

Some other major findings which the authors point out are:

  • The crooked nose should be considered an anatomical 'three-level unit": skin-soft tissue envelope (SSTE),bony- cartilaginous framework, and internal lining. Each of these 3 layers plays a specific role for making the nose appear crooked.
  • Total septal reconstruction of the quadrangular cartilage maybe required in severe cases where there is extensive post traumatic or iatrogenic alteration of the cartilage. According to above authors reshaping techniques under those conditions provides poor long term functional and cosmetic results because the original deformities tend to reoccur. 
  • Camouflage procedures are used to achieve better symmetry of the nasal contour anatomy  &/or emphasis some crucial surface landmarks (rhinion, tip definition points, pronasale, colemellar break, subnasale). Autogenous softly crushed septal cartilage, remnants of the cephalic alar resections, & mature scar tissue are the authors preferred additive camouflage material. 
  • The poor success rate of septum surgery reported by many studies is probably due to the failure to treat concomitant valve derangement & alterations of the lateral nasal wall. In fact, concomitant surgery on the nasal lateral wall is often required for a satisfactory functional outcome.  
  •  Precise mini-invasive endoscopic procedures on turbinates and ostiomeatal complex produce excellent functional results.
  •  Conventional osteotomy techniques do not always accomplish what was intended. Double and in special cases, triple osteotomies are necessary to mobilize completely the bony pyramid and change excessive broadness, convexity, or bowing of the nasal lateral walls.  
  • An often neglected region is the premaxillary area including the inferior nasal spine and the premaxillary wings. 
For further reading on chapter by above mentioned authors

Additional reading sources