Placement Of Intranasal Packs, Nasal Splint
When extensive septoplasty is undertaken, or when partial turbinectomy or turbinoplasty is performed, the surgeon may wish to place a temporary intranasal pack. The goal is to pro -vide some compression of the septa] flaps and, in the case of turbinate surgery, to decrease the risk of postoperative bleeding. There are a number of commercially available packs. An intranasal pack is typically left in place at most overnight and removed the next morning.
A great variety of splints are commercially available. In general, after placement of an appropriate adhesive, a small rectangular strip of Telfa is placed over the nasal dorsum to facilitate removal of the splint in 5 to 7 days. Tape is applied over the dorsum and the nasal tip. A splint is carefully applied.
Closure of the Marginal, Intercaetilaginous, or Transcartilaginous Incision
This incision is closed with one or two 5-0 chromic sutures located laterally that act to advance the lateral crura slightly toward the domes (Fig. 2) This suture advancement will negate the need for an additional suture placed in the region of the domes. All sutures used to close the marginal incision must be examined to make sure there is no distortion of the nostril rim or domal region. If the nostril rim is notched, then the suture should be replaced, taking a smaller bite.
The sutures should be removed from the columellar incision after 5 days. At that point, the incision may be supported with flesh-colored steri-strips for several weeks to act as antitension taping. Persistent postoperative supratip edema can be treated with subdermal injections of triamcinolone acetonide (Kenalog; 10 mg/ml, 0.1 ml) injected into the supratip region of the nose. These subdermal injections should not be used in any region other than the supratip and should not be used more frequently than once every 8 weeks. Superficial injections or excessive use can result in subdermal atrophy.
Closure of external rhinoplasty incisions.
If there is any tension on the closure, a midline 6-0 PDS suture can be applied to evert the skin edges. Special care must be taken to align the skin edges properly. If the subcutaneous suture is not placed properly, the result will likely be a visible scar.
The columellar incision is closed with the first?-0 nylon vertical mattress suture placed in the precise midline. The next two sutures are placed just off midline and are angled from medial on the lower flap to lateral on the upper flap. This maneuver will minimize the chances of creating a notch at the lateral aspect of the columellar flap.
After closing the marginal incision, the surgeon should check the alar margin to ensure that there is no notching of the margin. This occurs if too much mucosa is taken and acts to deform the alar rim.
The surgeon should examine the columellar extension of the columellar incision. In most cases, no suture is needed in this region because the vestibular skin is ad equately aligned. In some cases, the vestibular skin is not aligned properly, and a 6-0 chromic suture should be used to align the incision properly.
Application of the Cast
A strip of Telfa can be applied over the dorsum to allow the cast and tape to be re-moved without lifting the dorsal skin off the underlying nasal skeleton, with resulting edema.
The nose should be loosely taped to avoid vascular compromise. The tissues will become edematous, and if taped too tight, the tissues may become compromised.
An Aquaplast cast can be loosely applied to the nose and left in place for 5 days. At the time of cast removal, adhesive remover applied through the holes in the cast will loosen the tape. A blunt instrument can be used to lift the cast and tape care fully off the nose.
At the time of cast removal, the tape should be loosened with adhesive remover that is applied through the holes in the Aquaplast cast and allowed to work for 5 to 10 minutes.
Digital exercises can be used in the patient who has a deviated nose_ These patients can perform digital exercises on the nasal bones to avoid postoperative shifting of the bony nasal vault. This must be done within 10 days after surgery; otherwise, the bones will have started to fixate.
Postoperative steroid injections can be used to correct subtle asymmetries of the nose. Triamcinolone acetonide (Kenalog; 10 mg/ml) can be injected into the sub-dermal region where excessive asymmetric edema is noted.
- Toriumi DM, Johnson CM. Open structure rhinoplasty featured technical points and long-term follow-up. Facial Plast Surg Clin North Am 1993;1:1-22.
- Johnson CM Jr, Toriumi DM. Open structure rhinopla.sty. Philadelphia: WB Saunders, 1990.
- Tardy ME. Rhinaplasty: the art and the science. Philadelphia: WB Saunders, 1997.