<div>Use of osteosynthesis titanium micro-plates in rhinoplasty</div><div>Rui Xavier (1,2), Hugo Amorim (1), Dirk-Jan Menger (3), Henrique Cyrne
de Carvalho (2), Jorge Spratley (4)</div><div>1 Hospital Luz Arrabida, Porto, Portugal</div><div>2 Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto,
Porto, Portugal</div><div>3 University of Utrecht, Utrecht, The Netherlands</div><div>4 Faculdade de Medicina da Universidade do Porto, Centro Hospitalar e
Universitário S. João and Centro de Investigação em Tecnologias e
Serviços de Saúde (CINTESIS), Porto, Portugal</div><div>Ethical considerations:</div><div>This manuscript complies with all current ethical requirements. The
patient whose clinical case and photos illustrate this manuscript was
informed of this manuscript and signed a written consent for his case
and photos to be published.</div><div>The authors declare that they have no conflicts of interest to disclose</div><div>Corresponding author:</div><div>Rui Xavier</div><div><i>rjxavier65@gmail.com</i></div><div>Department of Otorhinolaryngology, Hospital Luz Arrabida</div><div>Praceta Henrique Moreira 150</div><div>4400-346 VNGaia – Portugal</div><div>Abstract</div><div>Objectives</div><div>To demonstrate that solid fixation of the nasal L-strut is possible even
in the most difficult clinical scenario of reconstructive rhinoplasty
ensuring good long-term results.</div><div>Settings</div><div>In most cases of reconstructive rhinoplasty, the nasal framework has to
be securely fixated to the facial bony skull. Solid points on the facial
skull for suturing the nasal framework are usually available but,
occasionally, may be absent. In these circumstances, alternative
solutions must be used.</div><div>Methods</div><div>We present a surgical technique to fixate the nasal L-strut to the
facial skull by using exclusively titanium L-shaped micro-plates in
cases where the anterior nasal spine and the nasal bones cannot be used
for providing fixation points.</div><div>The case of a patient with severe dysmorphia of the nose is presented as
illustrative of the technique. Four L-shaped titanium micro-plates
usually utilized for osteosynthesis were used to fixate superiorly
extended spreader grafts and a caudal septal extension graft to the
adjacent bony skull.</div><div>The reporting methods do not apply for this manuscript.</div><div>Results</div><div>This combined caudal and dorsal fixation of the nasal framework to the
facial bony skull by using titanium micro-plates has not been previously
described. Nevertheless, we were able to create a solid framework for
the nasal pyramid, ensuring a stable long-term result.</div><div>Conclusions</div><div>Even in the most difficult clinical scenario of reconstructive
rhinoplasty a solid fixation of the nasal L-strut is possible, by using
titanium micro-plates screwed to the facial bony skull. This fixation
has proved to be stable, providing good long-term results.</div><div>Keywords: Rhinoplasty, Titanium micro-plates, Nasal L-strut fixation,
Nasal framework, Reconstructive rhinoplasty</div><div>Key Clinical Message</div><div>Even in the most difficult clinical scenario of reconstructive
rhinoplasty a solid fixation of the nasal L-strut is possible. Fixation
by using titanium micro-plates screwed to the facial skull has proved to
be stable providing good long-term result</div><div>Introduction</div><div>The high degree of expectancy of the surgical outcome of rhinoplasty
from both the patient and the surgeon makes every single rhinoplasty
case a challenge. Reconstructive rhinoplasty is amongst the most
difficult cases, as rebuilding the nasal framework has the extra burden
of providing a solid midline structure upon which the nasal pyramid is
erected. Usually there are solid points on the bony facial skull for
suturing the nasal framework. In rare cases those solid points for
suturing cannot provide strong support and alternative solutions have to
be used. A surgical technique for fixation of the L-strut to the facial
skull using exclusively titanium micro-plates is described. An
illustrative clinical case in which this technique was used is
presented.</div><div>Clinical Case</div><div>The patient is a 28 years old male from African descent. In his medical
history there were no known history of nasal trauma or of nasal or
systemic diseases. The patient had no nasal airway obstruction but
wanted to undergo surgery to achieve an aesthetic improvement of the
nose.</div><div>Nasal analysis revealed an absent nasal dorsum with only the tip
protruding from the face (Fig.1). The nasal bones and ascendant
processes of the maxilla were flat, with no convexity and not sagittally
protruding from the facial plane. The middle third of the nose was
hypoplastic due to underdeveloped septal and upper lateral cartilages.
The nasal tip was wide and under projected, with insufficient support.
There was retraction of the caudal septum and the anterior nasal spine
could not be palpated. The nasal cavities had reasonable width on both
sides and the septum was at the midline.</div><div>A CT scan of the nose of the patient demonstrated a hypoplastic anterior
nasal spine (Fig.2a). The nasal bones were present though hypoplastic
and not protruding from the face as shown on the CT 3D reconstruction
(Fig.2b).</div><div>The patient wanted to undergo rhinoplasty for an aesthetic improvement
of the nose. He requested an increase in tip projection and in tip
definition, while preserving the ethnic features of his nose. Most
importantly, the patient desired to have a protruding nasal dorsum.
Given the specific features of the patient´s nose, the surgical plan for
the rhinoplasty was thoroughly discussed with the patient.</div><div>Surgical Report</div><div>Fascia from <i>pectoralis major</i> muscle and costal cartilage from the
7<sup>th</sup> rib were harvested. An extended open rhinoplasty
approach was used. The quadrangular septal cartilage was hypoplastic,
causing retraction of the caudal septum and leading to the low middle
third of the nose. The anterior nasal spine was barely palpable. Soft
tissues were elevated from the anterior surface of the premaxilla in
order to expose the bone of the premaxilla. Septal mucoperichondrial
flaps were raised bilaterally. The upper lateral cartilages were divided
from the dorsal septum. The nasal bones and ascending processes of the
maxilla were widely exposed up to the glabella.</div><div>Median and paramedian osteotomies were performed in order to remove a
wedge of the nasal bones at the midline. The gap thus created was used
to accommodate superiorly (and inferiorly) extended spreader grafts. No
other osteotomies were performed as not to destabilize the nasal bones
and ascending processes of the maxilla.</div><div>Extended spreader grafts from costal cartilage were docked in the gap
created between the nasal bones and positioned anteriorly in relation to
the plane of the nasal bones. The cephalic margins of the extended
spreader grafts were positioned to abut the frontal bone, in the
glabella. Titanium micro-plates bent in order to create L-shaped
micro-plates were used to fixate these grafts to the flat nasal bones. A
micro-screw (1.5 mm wide, 3 mm long) was screwed to fixate the
horizontal arm of the L-shaped titanium plate to the nasal bone and
another micro-screw was screwed to fixate the vertical arm of the
titanium plate to the lateral surface of the cephalic region of the
spreader graft (Fig.3). This attachment was done to both extended
spreader grafts.</div><div>A septal extension graft was created from two pieces of costal cartilage
sutured one to the other, with the concave sides facing inside. This was
done to prevent any deviation of the nasal tip off the midline due to
cartilage warping. This double-layered cartilage was then fixated to the
premaxilla using two L-shaped titanium micro-plates. A micro-screw was
screwed to fixate the horizontal arm of the L-shaped titanium plate to
the maxillary bone close to the anterior nasal spine and another
micro-screw was screwed to fixate the vertical arm of the titanium plate
to the lateral surface of the septal extension graft (Fig.4a) This
attachment was done on both sides of the septal extension graft.</div><div>The caudal region of the two extended spreader grafts was then sutured
to the anterior region of the septal extension graft with a
non-resorbable suture (Fig.4b,c).</div><div>Figure 5 illustrates how the extended spreader grafts and the caudal
extension graft were fixated to the bony skull in order to provide a
solid nasal framework. The upper lateral cartilages were sutured to the
spreader grafts and the medial crura of the lower lateral cartilages to
the septal extension graft in a tongue-in-groove fashion. Domal sutures
and an interdomal suture were used. A tip and an infratip graft were
both sutured in place. Free diced cartilage was placed in the radix in
order to smooth the contour of the nasofrontal angle as well as between
the two extended spreader grafts to fill the space between the grafts. A
dorsal onlay graft from costal cartilage was sutured over the nasal
dorsum, to increase dorsal projection. A layer of <i>pectoralis
major</i> fascia was placed over the nasal dorsum, in order to smooth the
contour of the nasal dorsum.</div><div>A septal mattress suture was used and the marginal and columellar
incisions were sutured using a fast resorbing suture material. An
external cast with a thermic splint was used. Intra-nasal packing was
not used.</div><div>The patient was discharged on the day after surgery. He was prescribed
oral amoxicillin-clavulanic acid for 8 days, paracetamol as required,
and was instructed to apply an ointment with gentamicin and
dexamethasone over the sutures twice a day and to do intranasal lavages
with saline for eight weeks. The external cast was removed 10 days after
surgery.</div><div>Two years after surgery the rebuilt nasal framework remains stable and
securely attached to the facial skull by the four L-shaped titanium
micro-plates. No signs of infection or of extrusion of the screws have
occurred during this time. The pre-operative photos and the two years
post-operative photos of the patient are shown in Figures 1a,b,c,d and
6a,b,c,d.</div><div>Discussion</div><div>Every rhinoplasty case is a challenge. The degree of sophistication of
rhinoplasty has reached to a point where results are expected to be
perfect, leaving little room to a suboptimal outcome. Reconstructive
rhinoplasty is amongst the most difficult rhinoplasty cases, as the
nasal framework has to be significantly reinforced or even completely
rebuilt. Upon this rebuilt nasal framework the nasal pyramid can be
erected to provide shape to the external nose and an efficient airway.</div><div>Usually there are solid bony points for suture fixation of the new nasal
framework, namely the anterior nasal spine for caudal fixation and the
nasal bones and ascending processes of the maxilla for cephalic fixation
of the nasal L-strut. These can be drilled to make holes where suture
material can be passed to strongly secure the cephalic part of the nasal
L-strut. Alternatively, the transcutaneous transosseous cerclage suture
described by Haak <i>et al</i> (1,2) can also be used for fixating the
dorsal part of the nasal L-strut to the adjacent facial bones. A
straight osteotome or a powered instrument can be used to create a notch
in the anterior nasal spine where the caudal and posterior part of the
L-strut can be slipped in or a hole may be drilled on the anterior nasal
spine in order to suture the caudal margin of the L-strut. In this way,
a nasal framework solidly secured to the facial skull can be achieved,
ensuring a stable long-term outcome.</div><div>In rare instances these traditional solutions can not be used. This was
the case of the patient that we present. Due to the shape and
orientation of the nasal bones and ascending processes of the maxilla,
which were not sagittally protruding from the plane of the face, these
could not be used for the traditional types of suture attachment of the
nasal L-strut. Moreover, due to the almost complete absence of the
anterior nasal spine, also the usual caudal fixation of the nasal
framework could not be used. Therefore, alternative solutions had to be
found. We used four titanium micro-plates bent into a L-shape for
securing the nasal framework to the facial skull.</div><div>The use of titanium micro-plates to fixate the caudal part of the nasal
framework to the maxilla in cases of absent anterior nasal spine has
been described (1,3), but using titanium micro-plates to fixate
superiorly extended spreader grafts to the nasal bones and adjacent
ascending processes of the maxilla has not, to our knowledge, been
previously described.</div><div>Mittermiller <i>et al</i> (3) used titanium plates in the premaxilla for
suturing the caudal septum in cases of absent anterior nasal spine. Haak<i>et al</i> (1) used titanium plates for fixating a transposed anterior
nasal spine to the midline or to substitute the anterior nasal spine. In
the nasal dorsum titanium plates have been used to fixate the dorsal
septum to the nasal bones in cases of traumatic fractures of the nasal
septum (4) and to fixate fragments of fractured nasal bones or ascending
processes of the maxilla (4). Titanium microplates have also been used
in the nose as stents sutured to the undersurface of costal cartilage
grafts to prevent warping of the grafts or sutured as stents to the
L-strut to stabilize the anterior septal angle (3,5).</div><div>Titanium plates have been widely used in maxillo-facial surgery with not
significant host reaction or extrusion. Therefore, we felt confident to
use titanium micro-plates in the nose. The risk of infection of these
implanted materials was low due to the fact that the micro-plates and
the screws were not in contact with the nasal airway or with the nasal
mucosa at any stage of the surgery or afterwards. In the clinical case
that we report, there was no infection in the two years that have passed
since the rhinoplasty.</div><div>In our clinical case both the cephalic and the caudal margins of the
newly created nasal framework were fixated to the face by titanium
micro-plates. This has not been previously reported. We bent the
titanium micro-plates as to mold each one with the L-shape that would
suit our fixation requirements. Differently from previous descriptions
of titanium plates used in the nose (1,3), we did not suture the grafts
to the micro-plates; instead, we screwed the micro-plates to the bone
and to the costal cartilage grafts with micro-screws. Screwing these
titanium micro-plates to grafts made from strong costal cartilage led
the impression of a stable attachment. Nevertheless, after being
screwed, the extended spreader grafts could be gently tilted as needed
in order to make fine adjustments of the angulation of these grafts and
to set the ideal relative position between the extended spreader grafts
and the septal extension graft. The length of the micro-screws that we
used (3 mm) was very appropriate to secure the titanium micro-plate to
the bone without over-passing the depth of the bone. Some over-pass of
the screws on the extended spreader grafts did happen, but the excess of
the length of the screws was well concealed between the two spreader
grafts.</div><div>An extended open approach was necessary to allow drilling and screwing
the titanium micro-plates to the facial skull. This may have led to more
significant local edema, but did not prevent the patient from being
discharged on postoperative day one.</div><div>The specific anatomical features of the patient led us to use this
surgical solution. The ethnic African nose of the patient is not a
justification for the complete absence of nasal dorsum, and there was no
known reason for that. No systemic or local disease was present. The
blood tests conducted were all normal and the patient was healthy. He
did not report any previous nasal trauma, but perhaps some form of
trauma had occurred during childhood. This could have led to the
abnormal shape and position of the nasal bones and ascending processes
of the maxilla as well as to some resorption or under-development of the
anterior nasal spine and cartilaginous middle third of the nose.
Remarkably, despite the absence of nasal dorsum, the patient had no
complaints of nasal airway obstruction.</div><div>Other surgical solutions could have been used to address this patient.
As the patient had no nasal airway obstruction the option of using
superiorly and inferiorly extended spreader grafts positioned anteriorly
to increase the height of the nasal dorsum plus a cartilaginous dorsal
onlay graft could have been disfavored to a simpler cantilevered dorsal
onlay graft. However, we thought that the necessary height of this onlay
piece of cartilage could have created a heavy burden over the
underdeveloped cartilages of the middle third of the nose eventually
creating nasal airway obstruction. Composite reconstruction of the nasal
dorsum using spreader grafts normally positioned together with a dorsal
onlay graft of glued diced cartilage or diced cartilage in fascia could
have been another option, but we thought that expecting a strong new
dorsum from this diced cartilage graft in a patient with no nasal dorsum
and with thick skin would be over optimistic.</div><div>Fascia from <i>pectoralis major</i> muscle was harvested from this
patient, as previously described (6). This patient, from African
descent, had thick skin. Nevertheless, we felt more confident to use a
layer of fascia over the rebuilt nasal dorsum to prevent any
irregularity of the grafts to become apparent in the long-term.</div><div>The surgical solution that was taken has proved to remain stable over
time, as shown by the two-years postoperative photos of the patient. We
are confident that the strong nasal structure that was created by using
costal cartilage grafts screwed to the facial bones will stand the test
of time and will ensure a stable long-term result. No signs of local
reaction or extrusion of the titanium micro-plates or of the screws have
occurred during these two years. Nevertheless, we will continue to
observe the patient as we believe that rhinoplasty is a life-long
commitment between surgeon and patient.</div><div>Conclusions</div><div>A distinctive feature of modern rhinoplasty is the ability to
incorporate expertise and solutions from other medical fields into nasal
surgery, in the continuous search for improving the results. When the
traditionally used facial bony structures cannot be used for suture
fixation of the nasal L-strut other solutions have to be used, in order
to achieve the ultimate goal of a solid nasal framework that will ensure
a stable long-term outcome. We describe a new way of fixating the nasal
framework to the facial skull by using exclusively titanium
micro-plates. This surgical solution, though not frequently necessary,
can be incorporated in the armamentarium of the rhinoplasty surgeon.</div><div>The authors declare that they have no conflicts of interest to disclose.</div><div>Author contributions:</div><div>Rui Xavier: conception and design, acquisition of data, analysis and
interpretation of data, drafting the manuscript, revising it critically
and given final approval of the version to be published.</div><div>Hugo Amorim: conception and design, acquisition of data, analysis and
interpretation of data.</div><div>Dirk-Jan Menger: conception and design, revising the manuscriopt
critically and given final approval of the version to be published.</div><div>Henrique Cyrne de Carvalho: conception and design, revising the
manuscriopt critically and given final approval of the version to be
published.</div><div>Jorge Spratley: conception and design, interpretation of data, drafting
the manuscript, revising it critically and given final approval of the
version to be published.</div><div>Acknowledgement statement:</div><div>None</div><div>References</div><ol><li>Haack S, Hacker S, Mann S, Gubisch W. Bony fixation of the nasal
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2015; 39(3):300-305</li></ol><div>Figure legends</div><div>Fig.1a,b,c,d Preoperative photos of the patient</div><div>Fig.2a,b 3D reconstruction from the CT scan showing the abnormal nasal
bone structure of the patient (a) and the flat nasal bones (b)</div><div>Fig.3a,b,c Titanium micro-plate screwed to the nasal bone and to the
cephalic margin of the spreader graft on each side</div><div>Fig.4a,b,c Titanium micro-plate screwed to the premaxilla and to the
caudal part of the caudal extension graft on each side of the midline
(a) and fixation of the extended spreader grafts to the caudal extension
graft (b,c)</div><div>Fig.5 Illustration of the nasal framework fixation to the bony skull
with titanium micro-plates</div><div>Fig. 6a,b,c,d Two years postoperative photos of the patient</div>