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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 24  |  Issue : 1  |  Page : 12-16

Assessment of functional and esthetic outcomes of external approach septorhinoplasty with spreader graft in North India


Department of Otorhinolaryngology and Head and Neck Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Submission08-Jul-2021
Date of Acceptance15-Aug-2021
Date of Web Publication30-Mar-2022

Correspondence Address:
Dr. Sandeep Trehan
B-187, Mansarovar Garden, New Delhi - 110 015
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjoh.sjoh_31_21

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  Abstract 


Introduction: Rhinoplasty is one of the most commonly performed facial plastic surgeries. Esthetic rhinoplasty can be exclusively esthetic or for both functional and esthetic concerns combined. The spreader graft can be used as a spacer where a patient with nasal obstruction who is also having external nasal deformity can be benefitted in both the areas. Objectives: The objective is to assess the functional and esthetic outcomes pre- and post-operatively in patients undergoing external approach rhinoplasty with spreader grafting. Methodology: Thirty patients were included in the study. Internal valve collapse was confirmed by modified Cottle's maneuver and diagnostic nasal endoscopy. All surgeries were done using an external approach under general anesthesia. Pre- and post-operative nasal obstruction symptom evaluation (NOSE) and rhinoplasty outcome evaluation (ROE) score were taken. Results: The preoperative NOSE score average was 64.5. After 3 months of postoperative follow-up, the NOSE score reduced to a mean value of 11.83. The preoperative ROE score average was 6.73. Postoperative ROE score improved to a mean value of 18.83. Conclusion: Rhinoplasty is a delicate, skill demanding surgical procedure which, when done along with a spreader graft will be beneficial both functionally and cosmetically in patients with external nasal deformity with obstruction symptoms. Comparison of esthetic and functional results could be done further in future studies which will provide further inputs in the field of rhinoplasty.

Keywords: Internal nasal valve, nasal obstruction symptom evaluation score, rhinoplasty, rhinoplasty outcome evaluation score, spreader graft


How to cite this article:
Ponnusamy S, Trehan S, Lade H, Bhardwaj R. Assessment of functional and esthetic outcomes of external approach septorhinoplasty with spreader graft in North India. Saudi J Otorhinolaryngol Head Neck Surg 2022;24:12-6

How to cite this URL:
Ponnusamy S, Trehan S, Lade H, Bhardwaj R. Assessment of functional and esthetic outcomes of external approach septorhinoplasty with spreader graft in North India. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2022 Jul 2];24:12-6. Available from: https://www.sjohns.org/text.asp?2022/24/1/12/341361




  Background Top


Rhinoplasty is one of the most commonly performed facial plastic surgeries which is increasingly sought after in this decade. Rhinoplasty is done for both functional and exclusively esthetic requirements.

Functional rhinoplasty is done with an aim to relieve the nasal obstruction caused by anatomical alterations including internal nasal valve collapse, high septal deviation, reduced lateral wall support, and external valve stenosis. The internal nasal valve which is bounded by nasal septum medially, upper lateral cartilage, and anterior end of inferior turbinate laterally and nasal floor inferiorly; constitutes for about 13% of causes of nasal obstruction; though described as early as 1903 by Mink,[1],[2] still lacks due consideration in the management even at the tertiary care levels.

Esthetic rhinoplasty can be exclusively esthetic where a patient comes with cosmetic concerns or “functional–aesthetic” where a patient with nasal obstruction who is also having external nasal deformity with dorsal septal deviation and crooked middle vault can be benefitted in both the areas from a rhinoplasty surgeon. The esthetic expectations and prevalent dorsal esthetic lines vary among ethnic groups and have to be taken into consideration. At the same time, realistic expected outcomes to be explained and counseled to the patients, considering the fact that quite a percentage of patients with body dysmorphic disorder also approach rhinoplastic surgeons.[3]

The spreader graft can be used as a spacer which separates the upper lateral cartilage from the dorsal septum and to keep the septum in a straight line. Though initially described by Sheen[4] in an endonasal procedure, the external approach rhinoplasty is mostly preferred despite the columellar scar and postoperative swelling because of its clear advantages in terms of exposures bi-manual operational freedom, ease and precision in placement of the graft and suture fixation preventing its displacement.[5],[6]

There are numerous objective and subjective methods of estimation of outcomes of rhinoplasty of which the objective methods like the rhinomanometry and acoustic rhinometry showed inconsistent results among operators and did not correlate well clinically.[7],[8] Estimation of success in a rhinoplasty surgery is based on patient satisfaction and in turn, patient gratification is subjective. Nasal obstruction symptom evaluation (NOSE) scale and rhinoplasty outcome evaluation (ROE) are validated scales of subjective outcome evaluation for functional and esthetic rhinoplasty, respectively.[9],[10]

Very few studies have compared the functional and esthetic outcomes and the aim of our study is to assess and compare them pre- and post-operatively in patients undergoing external approach rhinoplasty with spreader grafting in our tertiary care center.

Patient sample

Thirty patients who came from the areas around New Delhi in North India were included in the study who met the inclusion criteria. Patients from both the sex who had symptomatic nasal obstruction and with external nasal deformity were included in the study. Patients below 18 years of age and who had previous nasal surgery were excluded from the study.


  Methodology Top


After taking informed consent and detailed history, all patients underwent complete ears, nose, throat examination. The approval number of the ethics committee was taken with S. No . IEC/VMMC/SJH/Thesis/October/2017-076. The internal valve collapse was confirmed by modified Cottle's maneuver using a Cottle's elevator[11] and diagnostic nasal endoscopy [Supplementary Figure 1]. Dynamic valve collapse due to weak lateral cartilage wall is observed clinically and excluded. Preoperatively the NOSE scale and ROE scale scoring was noted and photo documentation was done.



All surgeries were done using an external approach under general anesthesia. Bilateral marginal incisions were made and combined with either transcolumellar seagull incision or step ladder incision; the supra perichondrial and subperiosteal planes were raised to open the vaults of the nose. The cartilage graft was harvested from the deviated part of the nasal septum. Osteotomies were performed when there was a deviation of superior vault and rasping was done in cases with hump deformity. The upper lateral cartilages (ULC) on both sides were separated from the septum with a sharp incision without disturbing the keystone area. Thin slices of cartilage spreader grafts were interposed between the ULC and septum and fixed with 5-0 vicryl sutures. After skin closures, splints were applied for 7 days in the postoperative period [Figure 1], [Figure 2], [Figure 3], and [Figure 4].
Figure 1: Preoperative picture

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Figure 2: Postoperative picture after 3 months

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Figure 3: Exposure of middle vault

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Figure 4: Spreader grafts being placed

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Postoperatively, the patients were followed up for 3 months; the NOSE scale and ROE scores were compared with preoperative scores. Postoperative endoscopy and facial photo documentation were done till 3 months' follow-up.

Patients were questioned about the severity of the following symptoms over the past 1 month and the responses were evaluated and noted. The scale has 5 parameters with scores of 0–4 for each, a total of 20 is multiplied by 5 to get a maximum score of 100 [Table 1], [Graph 1].
Table 1: Nasal obstruction symptom evaluation instrument

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Patients were asked about the esthetic factors for which they want to undergo the surgery; the responses were evaluated and noted. The scale has 6 parameters with 0–4 scores (total score–24) [Table 2], [Graph 2].
Table 2: Rhinoplasty outcome evaluation instrument

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Statistical analysis

Results were analyzed using Microsoft Office Excel and Statistical calculations were done using SPSS software version 21. Data collected were grouped and expressed as frequency and percentage. Numerical data were expressed as mean ± standard deviation. Appropriate tests were used for statistical analysis and a P < 0.05 was considered statistically significant.


  Results Top


Thirty patients were included in the study and it was conducted from September 2017 to December 2018. The mean age was 23.33 ranging from minimum of 18 and maximum 36. Of which 43.3% were ≤ 20 years of age, 43.3% were between 21 and 30 and 13.3% were > 30 years of age. 6.7% were female and 93.3% were male.

The preoperative NOSE score average was 64.5 with a standard deviation of 11.92 (range 45–85).

After 3 months of postoperative follow-up, the NOSE score reduced to a mean value of 11.83 with a standard deviation of 8.56 (range 0–30).

Two patients showed a postoperative NOSE score of 30 both of their preoperative scores fall into the severe category of NOSE scale grading (55–75). All 8 (26.6%) patients with preoperative score of extremely severe category (75–100) had postoperative scores < 30.

The preoperative ROE score average was 6.73 with a standard deviation of 2.39 (range 2–12).

At 3 months of postoperative follow-up, the ROE score improved to a mean value of 18.83 with a standard deviation of 2.55 (range 11–23).

One patient had the postoperative ROE score of 11.


  Discussion Top


Patients may approach a rhinoplasty surgeon for various concerns including nasal obstruction, recruitment into an esthetically and functionally demanding job, exclusive esthetic reasons.

Though septorhinoplasty is a commonly performed surgery, it is at the same time a highly challenging and delicate surgery where, proper patient selection, preoperative surgical planning, elaborate counseling with realistic expectations are of paramount importance. The external approach rhinoplasty is preferred for its due advantages and with proper closure even the transcolumellar scar will be inconspicuous.

Although the osteotomies and grafts are to be decided and tailored for individual patients, most of the patients with crooked nose deformity have dorsal septal deviation. In patients with hump deformity, after hump reduction and rasping, medialization of dorsal structures done to prevent an open book deformity. In both of these scenarios the internal nasal valve is compromised which warrants a spreader graft placement during rhinoplasty for the surgery to be successful both functionally and esthetically.

NOSE scale is a validated scoring system which is being commonly used in the evaluation of functional outcome of various nasal surgeries. Although all patients had improvement in their postoperative NOSE score, two patients (6.66%) had postoperative scores of 30 which falls into moderately severe nasal obstruction category (30–50).[12]

The average preoperative score of 64.5 reduced in the 3 months of follow-up to an average of 11.83 which is statistically significant (P < 0.001). This is inconsistent with previous literature including a study conducted by Gerecci et al. where the patients were followed up till 10 months and there was no significant change in value after 3 months. This study gives the option of 3-month follow-up to the further rhinoplasty studies in place of 1 year follow-up.[13]

For the subjective analysis of esthetic results, various scales are used in literature including ROE scale and visual analog scale. ROE scale has been widely used and validated in the literature in the analysis of the septorhinoplasty. The scale has 6 parameters with 0–4 scores making a total score of 24, of which a score of > 12 is taken as satisfactory.[10] The ROE scale improved from a preoperative average of 6.73 to postoperative average of 18.83 with a statistical significance of P < 0.04. In this, 29 patients (96.66%) had a significant improvement in the esthetic score but one patient (3.33%) had a dissatisfactory postoperative score of 11.


  Conclusion Top


Rhinoplasty is an exquisite and ingenious cosmetic surgical procedure, which demands good skills and wider outlook. The use of spreader graft, in particular, provides a comprehensive domain for patients requiring functional and cosmetic correction.

With the quantum leap in various rhinological procedures in the modern era, adaptation plays a very important role. As far as, nasal framework surgery is concerned, due importance should be given to internal nasal valve anatomy during external nasal deformity correction, both of which can be addressed well by the spreader graft. Although further studies comparing the esthetic and functional results are required for advancement in the field of cosmetic rhinology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mink PJ. Le nez comme voie respiratorie. Presse Otolaryngol (Belg) 1903;21:481-96.  Back to cited text no. 1
    
2.
Elwany S, Thabet H. Obstruction of the nasal valve. J Laryngol Otol 1996;110:221-4.  Back to cited text no. 2
    
3.
Veale D, De Haro L, Lambrou C. Cosmetic rhinoplasty in body dysmorphic disorder. Br J Plast Surg 2003;56:546-51.  Back to cited text no. 3
    
4.
Sheen JH. Spreader graft: A method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 1984;73:230-9.  Back to cited text no. 4
    
5.
Constantian MB. Differing characteristics in 100 consecutive secondary rhinoplasty patients following closed versus open surgical approaches. Plast Reconstr Surg 2002;109:2097-111.  Back to cited text no. 5
    
6.
Gunter JP. The merits of the open approach in rhinoplasty. Plast Reconstr Surg 1997;99:863-7.  Back to cited text no. 6
    
7.
Teymoortash A, Fasunla JA, Sazgar AA. The value of spreader grafts in rhinoplasty: A critical review. Eur Arch Otorhinolaryngol 2012;269:1411-6.  Back to cited text no. 7
    
8.
Yeung A, Hassouneh B, Kim DW. Outcome of nasal valve obstruction after functional and aesthetic-functional rhinoplasty. JAMA Facial Plast Surg 2016;18:128-34.  Back to cited text no. 8
    
9.
Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg 2004;130:157-63.  Back to cited text no. 9
    
10.
Izu SC, Kosugi EM, Brandȧo KV, Lopes AS, Garcia LB, Suguri VM, et al. Normal values for the Rhinoplasty Outcome Evaluation (ROE) questionnaire. Braz J Otorhinolaryngol 2012;78:76-9.  Back to cited text no. 10
    
11.
Sun WH, Wang PC, Hsu SY. Spreader graft to correct nasal valve stenosis with high septal deviation. B-ENT 2018;14:287-93.  Back to cited text no. 11
    
12.
Lipan MJ, Most SP. Development of a severity classification system for subjective nasal obstruction. JAMA Facial Plast Surg 2013;15:358-61.  Back to cited text no. 12
    
13.
Gerecci D, Casanueva FJ, Mace JC, Annen A, Barrett DM, Kim MM, et al. Nasal Obstruction Symptom Evaluation (NOSE) score outcomes after septorhinoplasty. Laryngoscope 2019;129:841-6.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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