Endoscopic Surgery and Rhinoplasty Procedures
Concurrent Functional Endoscopic Sinus Surgery and Rhinoplasty
Traditionally surgeons have avoided performing rhinoplasty in conjunction with sinus surgery for rhinosinusitis. With advances in rhinoplasty and endoscopic sinonasal surgery and its added benefits of precision, minimal trauma, and hemorrhage, the combined procedure is now feasible. The indications, management, and results are discussed in 40 patients who underwent the combined procedure. Patients were divided into three categories based on the location and severity of the sinus disease: mild, moderate, or severe. The majority of patients had mild or moderate sinus disease. The most common presenting symptoms were nasal obstruction and postnasal drip. All patients had a history of sinusitis recalcitrant to conservative medical management. Results demonstrate the combined treatment modality to be safe and effective in patients with mild to moderate sinus disease and in selected patients with severe sinus disease.
Rizk SS, Edelstein DR. Matarasso A. Concurrent functional endoscopic sinus surgery and rhinoplasty. Ann Plast Surg
Classically, plastic surgeons have avoided performing rhinoplasty in the presence of acute or chronic rhinosinusitis due to the potential for infection. For the otolaryngologist, concurrent rhinoplasty can produce increased periorbital swelling and ecchymosis, which may potentially obscure the parameters used to monitor for complications of the sinus procedure .
Over the past decade, the advent of endoscopic sinus surgery using the Messerklinger technique, which restores the natural drainage of the sinuses, has resulted in more effective and less radical sinonasal surgery . Moreover, the increased utilization of computed tomography (CT) scanning in the management of sinusitis has led to more precise localization of sinus anomalies. These advances have made the simultaneous procedure safe and efficacious in appropriately selected patients with sinusitis. The purpose of this report is to identify the indications and limitations of the simultaneous procedures.
Patients and Methods
Forty patients were treated by this combined modality and 30 (75%) were available for follow-up. An additional 6 patients, who were referred by the plastic surgeon (AM), with sinus symptoms were not deemed to be appropriate candidates by the sinus surgeon (DRE). Seven patients also referred to the otolaryngologist refused to consider the combined procedure and underwent sinus surgery and rhinoplasty separately. There were 23 women and 17 men with a mean age of 33 years (range, 16-51 years) who underwent the combined approach. All had chronic rhinosinus-itis refractory to medical therapy and underwent the combined procedure by the same otolaryngologist and plastic surgeon. All patients were initially seen by the plastic surgeon for aesthetic concerns. Those patients with significant complaints of breathing problems or sinus disease were referred for otorhinolaryngological consultation. Plastic surgery consultation included a discussion with the patient about desired changes and expectations, and a preoperative photographic series.
The otorhinolaryngological workup consisted of a thorough history, complete head and neck examination, office fiberoptic or rigid nasal endoscopy, as well as fine-cut (4 mm) CT scanning of the paranasal sinuses (axial and coronal views). Prior to proceeding with the surgery, all patients had clearly defined anatomic abnormalities identified on CT scans. Common obstructive anomalies identified on the CT scan included simple deviation of the nasal septum, polyposis in the region of the ostiomeatal unit, enlargement of the middle and inferior turbinates, and nasal pyramid deflections. In addition to anatomic anomalies in the nose and sinuses, allergy and recurrent sinus infections contribute to chronic sinusitis. Rhinomanometry and allergy testing (radioallergosorbent blood test or skin test) were performed when indicated by history. All patients had multiple trials of broad-spectrum antibiotics (i.e., cephalosporins, trimethoprim/sulfamethoxazole, amoxicillin/clavulanate, quinolones), decongestants (i.e., phenylpropanolamine, oxy-metazolino), antihistamines if appropriate (i.e., loratidine, terfenadine), and intranasal topical steroids (i.e., budesonide, beclomethasone). A decision to proceed with surgery for chronic sinusitis was offered to the patient after 3 months of failed medical management with minimal or no relief of the sinus symptoms. The rhinoplasty was therefore delayed until all conservative medical measures were exhausted. The patients were started on broad-spectrum antibiotics to cover sinus organisms 1 week prior to surgery
Thirty-three patients received general anesthesia and 7 patients had monitored anesthesia with sedation. In those patients who had general anesthesia, the oropharynx was packed with gauze and the endotracheal tube cuff was inflated to protect the airway from aspiration of blood and secretions. At the conclusion of the procedure, the oropharyngeal pack was removed and the oropharynx examined for bleeding. The oropharynx was suctioned prior to extubation and the patients were reversed from general anesthesia. In those patients who underwent monitored anesthesia with sedation, the head of the bed was elevated 30 degrees during the procedure to aid in clearing secretions and the anesthesia was kept as light as possible.
In all patients the nose was anesthetized topically with 4% cocaine-impregnated pledges and intranasally with 1% xylocaine with epinephrine 1:100,000. All patients received intravenous ce-fazolin (1 g) and intramuscular celestone (6 mg in females and 9 mg in males) perioperatively. The submucous resection of the nasal septum was performed first through a standard hemitransfix-ion incision. Next, endoscopic sinus surgery was done by enlarging the openings of the affected sinuses, removing diseased mucosa using various biting forceps, and taking relevant cultures, if necessary. Those patients with turbinate involvementhad a partial resection of the inferior or middle turbinates. The hypertrophied inferior turbinates were excised by a partial removal of the lateral and inferior portions while preserving the integrity of the medial and superior mucosal surfaces. In 3 patients with a concha bullosa, a partial middle turbinectomy was performed using endoscopic curved scissors to remove the inferior and lateral portions. Finally, a closed rhinoplasty was performed after converting the hemitransfixion into a complete transfixion incision. No alteration was made in the rhinoplasty as a consequence of the sinus surgery. None of the patients had autogenous or alloplastic grafts. At the conclusion of the procedure, the nose was packed with telfa and half-inch Vaseline-impregnated gauze, and an aquaplast nasal splint (Aquaplast Corporation, Wycoff, NJ) was applied. Patients were transferred to the recovery room and observed for airway disturbances, bleeding problems, or visual changes. Patients remained in the recovery room until they were fully awake, cooperative, and able to assist in clearing their secretions. The nasal packing was removed within the first 24 hours. Postoperatively the patients were followed by both surgeons. Their care consisted of continued oral antibiotics for a minimum of 1 week postoperatively, and weekly office suctioning and debridement of the nasal cavity for the first month postoperatively and as needed thereafter by the otolaryngologist. Nasal saline irrigations and topical intranasal corticosteroids were resumed. Additional oral antibiotics were administered as indicated for evidence of a recurrent acute infection during the postoperative follow-up by the otolaryngologist. The otolaryngologist followed the patients quarterly during the first year. Postoperative photographs were recommended at 1 year.
Forty patients were treated with the combined modality and 30 were available for follow-up. The 6 additional patients who requested the combined procedure and who were excluded were bypassed due to severe sinus disease that precluded the combined treatment. The patients were classified into three categories based on the
sinus symptoms and the CT scan staging I, II, and III (Table 1). In the mild category, patients had mild symptoms of sinusitis (nasal obstruction, postnasal drip) and stage I disease (unifocal nasal and sinus hypertrophic disease) confirmed by CT scan. In the moderate category, patients had more symptoms of sinusitis (sinus headaches, rhinor-rhea) and stage II disease (multifocal but discontinuous nasal and sinus hypertrophic disease) confirmed by CT scan. In the severe category, patients had more debilitating symptoms (anosmia, frequent headaches) and stage III disease (bilateral, multifocal, contiguous panpolypoid disease) usually involving the sphenoid or frontal sinuses and was confirmed on CT scan , In this series the majority of patients had mild or moderate sinus disease. The site of the sinus disease varied (Table 2). In this study the 3 patients who had sphenoid or frontal sinus disease were in the severe category. It is noteworthy that these areas are associated with more extensive disease, requiring a longer length of surgery with greater risks to the orbit and increased bleeding. Severe-category disease increases complications and is a relative contraindication to the combined procedure. The 1 patient who had postoperative epi-staxis was in the severe category of sinus disease. All patients had a history of nasal obstruction, deviated nasal septum, and an external nasal deformity. The moderate and severe sinus patients tended to have more significant deflections of the septum and larger nasal spurs. Eighty percent (N = 32) of the patients had a history of nasal trauma and 15% (N = 6) of the patients had a history of prior nasal or sinus surgery such as polypectomy, Caldwell-Luc, or limited submucous resection. The most common presenting symptoms in all three categories were nasal obstruction and postnasal drip. Other symptoms included sinus headaches and rhinorrhea (Table 3). Headaches were seen more commonly in the moderate and severe categories, and anosmia was seen exclusively in the severe group.
The order of the surgical procedures was to perform the submucous resection first, to provide exposure, followed by the endoscopic sinus procedure and turbinectomy, and finally the rhinoplasty. All patients underwent submucous resections of the nasal septum and rhinoplasty. The majority of patients had endoscopic surgery in the maxillary and ethmoid sinuses where disease was most commonly present (Table 4). Of the 29 patients who had a turbinectomy, 26 had a partial inferior turbinectomy for hypertrophic turbinates and 3 patients had a partial middle turbinectomy for concha bullosa.
Overall, mean follow-up time in the 30 patients available for review was 3 years (range, 6 months-7 years). All 30 patients reported a substantia] or total resolution of their sinus symptoms. The patients were also satisfied with the aesthetic outcome. No patients required revi-sional surgery by either surgeon.
Hemorrhage occurred postoperatively in 1 patient who presented 18 days after the procedure to the otolaryngologist for nasal cleaning and debridement. He had a unilateral anterior nasal hemorrhage that was controlled with a Merocel anterior nasal pack (Merocel Corporation, Mystic, CT) without any further bleeding on packing removal. There were no other complications (Table 5).
The surgical management of chronic rhinosinus-itis and nasal deformities has undergone substantial change over the past two decades due to both technical advances and changing philosophy, making the combined procedure feasible. In addition, the management of both the functional and aesthetic problems of a patient can be interrelated, and the simultaneous procedures complementary. For example, a deviated septum can contribute to a twisted nose, and nasal polyposis can widen and deform the nasal dorsum. In this study, 80% (N = 32) of the patients had a history of nasal trauma resulting in both an external nasal deformity as well as a deviated nasal septum. Some surgeons prefer to treat the dorsum first before resecting the septum because of the increased strength of an unmanipulated septum and also because they are certain how much septum remains. Our approach requires a reversal of that order because doing the submucous resection first allows room in the nasal cavity to visualize better and access the sinuses with the endoscopic equipment. Before performing the septal surgery both surgeons discussed their surgical plans, particularly relating to the extent of manipulation planned for the cartilaginous dorsum.
The combined surgical approach for aesthetic rhinoplasty and sinus surgery has been avoided for various reasons. From the plastic surgeon's point of view, operating in a potentially infected environment was not ideal. However, with the increased use and efficacy of antibiotics for chronic sinusitis, the potential for an infected environment is greatly reduced. All of our patients had been on multiple courses of antibiotics for many months and were additionally placed on a prophylactic course 1 week prior to surgery. The newer endoscopic approach avoids the traditional excision of the middle turbinate, which limits postoperative bleeding and subsequent scabs and infection. Endoscopy also provides intranasal access to all of the sinuses, thereby avoiding the multiple external approaches that were used in the past. In addition, the older intraoral sublabial bony incisions via the Cald-well-Luc approach to enter the maxillary sinuses were known to have sizable swelling and increased infection of dental origin as side effects that were not desirable after rhinoplasty.
From the otolaryngologist's perspective, concurrent rhinoplasty could potentially obscure the parameters used postoperatively to monitor the patient for complications. This is germane because complications of rhinoplasty can be similar to the those of sinus surgery :
Cerebrospinal fluid leak
However, the etiology for the complications may differ. Epistaxis after sinus surgery is usually related to the ethmoidal or sphenopalatine vessels, whereas hemorrhage after rhinoplasty is more likely related to the angular or lateral nasal vessels injured from one of the lateral osteotomy incisions .
Moreover, the trend toward more conservative resections in rhinoplasty and the advances in rhinoplastic techniques and instrumentation have resulted in a lower rate of complications . More conservative resections may reduce operative time, trauma, postoperative swelling, and ecchymosis.
Similarly, advances in functional endoscopic sinus surgery have resulted in decreased complications . The widespread use of the
nasal endoscope has allowed better visualization, and fine instruments promote more accurate sinus surgery. In the preendoscopic era, sinus surgery was performed with much larger instruments and involved more extensive procedures such as complete removal of the middle turbinate and the creation of an external window into the maxillary sinus through a Caldwell-Luc approach. These extensive procedures resulted in significant postoperative pain and increased complications. In 1925, Maltz , a New York rhinologist, first described techniques for entering the maxillary sinus endoscopically using the sinuscope. Thereafter, several other earlier reports of diagnostic procedures in the nose and sinuses were reported . However, it was not until the 1970s that Messerklinger described his techniques of diagnostic and therapeutic sinonasal endoscopy. These techniques were later introduced into North America and refined by Kennedy [2, 9].
Messerklinger  carefully documented the endoscopic anatomy and pathology in the middle meatal area—the confluence of drainage ostia of the maxillary, frontal, and anterior ethmoid sinuses. His observations provide the principles for limited resection of anatomic or mucosal defects that interfere with the normal ostiopetal mucociliary clearance. In most patients it is believed that chronic sinusitis results from obstruction of the sinus ostia that drain into the middle meatal area or ostiomeatal complex (OMC) . These key areas can be visualized on a coronal CT scan and anterior rhinoscopy. The frontal, anterior ethmoid and maxillary sinuses drain into the middle meatal area and comprise the OMC. Blockage in the OMC is believed to result in sinusitis  (Fig A). The goal of sinus surgery is to enlarge and clear the natural ostia of any obstruction (Fig B) to allow proper mucociliary drainage into the nose from the sinuses. Messer-klinger's [13, 14] techniques of limited resection have resulted in minimal bleeding, less postoperative pain and swelling, and decreased operative time, making the combined procedures possible.
Furthermore, the combined approach allows early preemptive and continuing otolaryngologi-cal care. By identifying those patients with combined problems preoperatively, one ultimately decreases the potential postoperative functional complaints. As proposed earlier by Shemen and Matarasso , the combined procedure is safe and effective with concurrent recovery time and overall shortened hospitalization. Their observations in a limited series have been supported by this larger population with longer follow-up time.
However, there are some limitations that preclude this combined modality. The location and severity of the sinusitis are the most important factors. More severe sinus disease, which most often occurs in the sphenoid and frontal regions, requires more extensive surgery, increased operative time, and may produce more postoperative swelling, pain, and bleeding . Therefore, surgery in this population should be considered on a case-by-case basis. The majority of the patients in this study had mild or moderate sinus disease not involving the frontal or sphenoid sinuses. Additionally, sinusitis with extension beyond the sinuses, such as periorbital or orbital cellulitis, is another limiting condition. In those patients, the need to monitor the patient's orbital signs postoperatively would be precluded by the additional ecchymosis and edema of the concurrent rhinoplasty.
Aesthetic limitations include procedures that result in excessive swelling and ecchymosis or increase the possibility of infection. Concomitant eyelid surgery and complex rhinoplasties may lengthen operative time and contribute to increased postoperative edema and ecchymosis. Our patients did not require graft material, but this may represent a relative contraindication to the simultaneous procedure due to the possibility of graft infection in an environment with sinus secretions.
Furthermore, certain medical conditions may be relative contraindications to the combined modality and may increase complications. Hypertensive patients may have increased intraoperative or postoperative hemorrhage and ecchymosis. Asthmatic patients who tend to have more severe polyposis and sinus disease may require more extensive debulking with increased bleeding. Diabetics, immunocompromised patients, and patients with conditions predisposing to infection or poor wound healing theoretically have an increased chance of infection and should be carefully considered for the combined procedure. These patients may need to have staged procedures.
A clear understanding of the indications and management between the otolaryngologist and the plastic surgeon, preoperative planning, and meticulous postoperative follow-up are essential for a successful outcome. We postulate that there may be intraoperative circumstances in which the planned combined modality will not be possible and a decision to stage the procedures might be necessary.
In conclusion, combined rhinoplasty and endoscopic sinus surgery can be performed safely and with good results in a select population of patients. Clear communication between both surgeons is necessary before, during, and after the procedure for optimal results. Both surgeons should appreciate the relative challenges and expectations for both types of surgery. Delegation of responsibility should be understood by both the physicians and the patient. As the limits of both specialties expand, a greater appreciation of common ground and combined approaches to complex patient complaints will provide for more cost-effective and successful care.
Samieh S. Rizk, MD
Dr Mark S. Granick (Philadelphia, PA): Dr Rizk, many of the patients we see for rhinoplasty come in with a complaint of nasal obstruction. What is your recommendation as far as a workup for the average patient who comes in with septal deviation and a complaint of obstruction?
Dr Rizk: If it is just nasal obstruction, I would get preoperative rhinpmanometric and allergy testing. I would also recommend otolaryngologic evaluation preoperatively. That way you are covered and can avoid blame for worsening obstruction.
Dr Henry M. Spinelli (New York City, NY): I have a question analogous to what Dr Granick just asked you. Why couldn't the plastic surgery audience do a reasonable workup as Dr Mark Constantian does?
Dr Rizk: They sure can, but if you suspect that they have symptoms of sinus disease or polyposis in addition to the nasal obstruction, then I would recommend that you obtain a baseline ENT evaluation and order a CT scan of the sinuses with axial and coronal views.
Dr Spinelli: What kind of edema do you have
postoperatively? It was my intuition that you might have more doing the endoscopic sinus surgery and then going on. These are all closed rhinoplasties?
Dr Rizk: Yes, closed rhinoplasties.
Dr Spinelli: What kind of postoperative edema do you have in comparison to those without endoscopic sinus procedures?
Dr Rizk: When you are working on the anterior ethmoid and maxillary sinuses, there usually is not that much edema, but when you get into the frontal or sphenoid sinuses, you can get more edema. That is one reason why I think diseases in those sinuses are less amenable to the combined procedure.
DrMarkB. Constantian (Nashua, NH): I should just like to take minor issue with one point, or to clarify something. In my opinion patients should never breathe worse after rhinoplasty, regardless of the indication for it. There are two things we can do if we do traditional rhinoplasties, or even modern ones, that can create airway obstruction without prior airway obstruction. One is resection of the cartilaginous roof, which destabilizes the internal valve and takes away the anterior support for the upper lateral cartilage, so they fall medially, and the patient has a new airway obstruction. The other thing you can do is reduce the lateral crura so much that you destabilize the external valve. You avoid that by making those identifications of valvular incompetence as well as septal obstruction preoperatively. Then you must remember, as you are performing whatever maneuvers that you are going to do, that you have to create imbalances that exist preoperatively or ones that you create during your aesthetic maneuvers. For instance, you resect the dorsal roof, so you put in spreader grafts. You recognize an incompetent external valve and you correct it. Then your patients should breathe better postoperatively 100% of the time.