CORRECTION OF SECONDARY RHINOPLASTY (LOCAL DEFORMATION AND HYPERTROPHY OF THE NOSE DORSAL BACK) IN COMBINATION WITH A PTOTIC NASAL

Background. With the development of rhinoplasty at the end of the 20th century, rhinoplasty became one of the most popular surgeries. The number of corrective secondary surgeries of the external nose is steadily increasing every year, despite the fact that septorhinoplasty is a complex functional and aesthetic operation. Early and late complications after septorhinoplasty, according to various sources and studies, make up from 1.9% to 21% of clinical observations [1]. Combined deformations of the external and internal nose, usually accompanied by functional disorders of nasal breathing, are a especially technically challenging task for a surgeon. A complex combined deformation of the external nose is rhinokyphosis with local hypertrophy of the nasal dorsum and ptosis of the nasal tip due to the peculiarities of instability of the cartilaginous supporting function of the columellar segment and the distal part of the nasal septum cartilage. Correction of this combined pathology has technical features and requires further improvement. Purpose. To adapt and improve the postoperative results in patients with local deformation of the nasal dorsum in combination with ptosis of the nasal tip and instability of the nasolabial angle. To evaluate the aesthetic effectiveness of the stability of the corrective bone-cartilaginous structure of the nasal dorsum and the frequency of possible complications after secondary rhinoplasty, such as postoperative deformations of the nose, local hypertrophy of the nasal dorsum, nasal tip prolapse and nasolabial deviation. Materials and Methods: For two years, from 2023 to 2024, we were using an adaptive technique for patients with combined pathology presenting with rhinokyphosis and nasal tip ptosis. The distinguishing features of our surgical procedure in patients with the combined pathology of rhinokyphosis and nasal tip ptosis were resection of the nasal hump with an oscillating saw using a thin, metallic, leaf-shaped attachment, and lateral osteotomy, performed with a piezosaw, aimed at mobilizing and narrowing the bony structures of the nose. The study group consisted of 24 patients (23 female and 1 male), all of whom underwent secondary corrective rhinoplasty in 2023-2024. Patients were divided into two groups of 12 each: a control group and a study group. The study group underwent secondary corrective rhinoplasty using an oscillating saw and a piezosaw. The control group underwent secondary corrective rhinoplasty using a chisel; nasal bone mobilization and hump reduction were performed using the “push down” technique. Technically, the correction of rhinokyphosis in combination with a ptotic nasal tip involves the following steps: (1) a complete wedge resection of the nasal septum was performed pre-maxillary; (2) the mucoperichondrium was dissected via intercartilaginous incisions, with complete tangential dissection from the osteochondral structure of the nose. Nasal hump reduction was performed in the following way; an endonasal rasp was inserted through the right or left intercartilaginous incision in such a way that the resected hump fragment of the nasal dorsumwas displaced into the prepared oval opening. After removing the dorsal hump fragment, osteotomy of the right and left sides of the nasal pyramid was performed with a piezotome. It should be noted that the osteotomy was done using the “low-to-low” technique. Next, the nasal dorsum was narrowed along its entire length, and the mobilized nasal bones were set in the midline axis of the nose. The following stepwas wedge-shaped resection of the caudal aspects of the upper lateral cartilages. The size of the cartilage fragments removed was determined by the ability to rotate the nasal tip and close the wedge-shaped defect of the nasal septum; excess cartilage tissue of the upper lateral cartilages was resected. After that, a semi-penetrating incision was made through which septoplasty was performed. That allowed the preservation of the septal cartilage in the ventral and caudal directions. The maneuver allowed the nasal tip to be rotated to the desired height and at a certain aesthetically advantageous angle. At the end of the operation, vasotomy wasperformed, the wedge-shaped wound of the nasal septum was sutured, the nasal cavity was irrigated with chlorhexidine, and hemostasis was controlled. Silicone splints were placed individually into the right and left nasal passages with through- and-through sutures to the nasal septum. A fixation splint was applied to the nasal dorsum. To monitor the stability of the nasal shape, as well as the condition of the skin of the nasal dorsum, it is recommended to replace the splint on days 4-7. The duration of wearing the nasal dorsal splint is 14-15 days. Results. After rhinoplasty in patients with rhinokyphosis and ptotic tip of the nose, the use of the above technique, which was aimed at preventing postoperative cicatricial deformities, such as nose bridge depression, nasal tip drooping, nasal tip deviations, uneven surface of the nasal bridge, after removing the nasal bridge splint on the 15th day, the majority of patients, 94,7%, were satisfied with the aesthetic and functional result. During the control examination of all operated patients after 6 months of postoperative observation, 98.3% of patients noted complete satisfaction with the aesthetic and functional result of the performed operation. Conclusion. The results of performed rhinoplasty aimed at correction (rhinokyphosis in combination with ptosis of the tip of the nose) using the above technique were analyzed. More than 96% of operated patients noted a positive aesthetic and functional stable result after 6 months of observation.