CRANIOMAXILLOFACIAL DEFORMITIES/SLEEP DISORDERS/COSMETIC SURGERY

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Concomitant Dorsal Preservation 60
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7 Rhinoplasty and Orthognathic 62
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9 Q1 Surgery: A Technical Note 65
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11 Q4 Seied Omid Keyhan, DDS, OMFS,* Hamid Reza Fallahi, DDS, OMFS,y 67
12 Gholamhossein Adham, DDS, OMFS,z and Behzad Cheshmi, DDSx 68
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Purpose: In the present report, we have introduced a novel technique for concomitant Le Fort I surgery
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and dorsal preservation rhinoplasty and reviewed the reported data.
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16 Patients and Methods: Concurrent surgery could be considered a suitable option for patients requiring 72
17 both upper jaw orthognathic surgery and rhinoplasty or those who are willing to undergo single-stage 73
18 concomitant rhinoplasty and orthognathic surgery. In the present technical note, we have introduced a 74
19 dorsal preservation rhinoplasty technique combined with Le Fort I surgery through an intraoral approach. 75
20 The advantages of this technique include its conservative design, avoidance of a second surgery and anes- 76
21 thetic, the ability to correct possible nasal defects caused by the Le Fort I osteotomy, keeping the keystone 77
22 area intact, and, most importantly, the possibility of concomitant surgery. However, recurrence of the 78
23 hump and nasal pyramid lateralization are among the problems that could be associated with this tech- 79
24 nique. These disadvantages might necessitate revision surgery. 80
25 Results: A total of 48 patients (23 females and 15 males) had undergone concomitant rhinoplasty and Le 81
26 Fort I surgery using a modified dorsal preservation technique. No patient reported dissatisfaction with the 82
27 results of surgery regarding the nasal and facial esthetics. No evidence of severe complications, such as 83
28 saddle nose, severe deviation, airway compromise, or severe asymmetry, was observed postoperatively. 84
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Conclusions: Based on our experience with patients and after at least 1 year of follow-up, the results of
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the present study suggest that this technique is straightforward and produces excellent results.
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Ó 2020 Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial
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Surgeons
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J Oral Maxillofac Surg -:1.e1-1.e10, 2020
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36 Orthognathic surgery and rhinoplasty are surgical pro- Proponents of concurrent rhinoplasty and orthog- 92
37 cedures performed for functional and esthetic pur- nathic surgery believe that this approach leads to a syn- 93
38 poses and contribute to an individual’s self-esteem.1 ergy between these procedures and significantly 94
39 Rhinoplasty can significantly alter the patient’s appear- improves the outcomes.3 95
40 ance, and orthognathic surgery provides facial har- To the best of our knowledge, no studies to date 96
41 mony by correcting skeletal deformities.2 have evaluated concomitant orthognathic surgery 97
42 98
43 *Private Practitioner and Delegate Researcher, Conflict of Interest Disclosures: None of the authors have any 99
44 Craniomaxillofacial Research Center, National Advance Center for relevant financial relationship(s) with a commercial interest. 100
45 Craniomaxillofacial Reconstruction; Craniomaxillofacial Research Address correspondence and reprint request to Dr Cheshmi: Fac- 101
46 Center, Tehran University of Medical Sciences; and Regenerative ulty of Dentistry, Boroujerd Islamic Azad University, PO Box 102
47 Medicine and Stem Cell Research Network, Shahid Beheshti 6915136111, Boroujerd, Iran; e-mail: Beh.cheshomi@gmail.com 103
48 University of Medical Sciences and Health Services, Tehran, Iran. Received December 7 2019 104
49 yPrivate Practitioner, School of Advanced Technologies in Accepted April 9 2020 105
50 Medicine, and Dental Research Center, Research Institute of Ó 2020 Published by Elsevier Inc. on behalf of the American Association of Oral 106
51 Dental Sciences, Shahid Beheshti University of Medical Sciences, and Maxillofacial Surgeons 107
52 Tehran, Iran. 0278-2391/20/30368-2 108
53 zPrivate Practitioner, Department of Maxillofacial Surgery, Dental https://doi.org/10.1016/j.joms.2020.04.015
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54 School, Guilan University of Medical Sciences, Rasht, Iran. 110
55 xPrivate Practitioner, Faculty of Dentistry, Boroujerd Islamic Azad 111
56 University, Boroujerd, Iran. 112

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129 FIGURE 1. Diagrams showing keystone area, upper lateral cartilages (ULCs), and lower lateral cartilages (LLCs). 185
130 Keyhan et al. Dorsal Preservation Rhinoplasty and Orthognathic Surgery. J Oral Maxillofac Surg 2020. 186
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132 and rhinoplasty in a large sample size of patients.1,4,5 most common disadvantages of concomitant upper 188
133 This conservative attitude might have resulted from jaw surgery and rhinoplasty include the potential for 189
134 some inherent disadvantages of conventional Le Fort airway compromise, endotracheal tube management 190
135 I osteotomy. These include the issues associated with during surgery, an inability to repair subtle nasal defor- 191
136 determining the nasal modification after maxillary os- mities owing to intraoperative swelling, the perfor- 192
137 teotomy; interruption of the nasal support system af- mance of rhinoplasty on an ‘‘unstable foundation,’’ 193
138 ter removal of the pyriform ligament from the and the patient’s lack of appreciation of nasal 194
139 pyriform aperture, which leads to separation of the deformities.12 195
140 septal nasal cartilage from the nasal spine; and soft tis- 196
141 sue swelling of the lips, cheeks, and paranasal area.6-9 197
142 Dorsal Preservation Rhinoplasty: Push- 198
To reduce the risk of adverse outcomes, which are
143 Down and Let-Down Techniques 199
mostly related to the midfacial changes after upper
144 jaw surgery, postoperative edema, and operative dura- In 1914, a new concept of dorsal preservation rhino- 200
145 tion, many clinicians believe rhinoplasty should be plasty was described by Lothrop.13 Cottle and Loring14 201
146 performed as a separate adjunctive surgery, performed in 1946 and Cottle15 in 1954 described the push-down 202
147 at least 6 months after the upper jaw surgery.10,11 The operation (PDO) as a technique in which the nasal 203
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167 FIGURE 2. Schematic diagrams of resections using push-down and let-down techniques. 223
168 Keyhan et al. Dorsal Preservation Rhinoplasty and Orthognathic Surgery. J Oral Maxillofac Surg 2020. 224

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FIGURE 3. Modified subnasal Le Fort I osteotomy.
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241 Keyhan et al. Dorsal Preservation Rhinoplasty and Orthognathic Surgery. J Oral Maxillofac Surg 2020. 297
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243 dorsum is maintained intact by the impaction of the subnasal Le Fort I osteotomy, preserving the pyriform 299
244 bony and cartilaginous hump around the keystone aperture ligaments. The maintenance of these liga- 300
245 area. The chief aim of the PDO is to maintain the ments has a significant and positive effect on the longi- 301
246 keystone area and preserve the continuity of the carti- tudinal results. Thus, dramatic and unpredictable 302
247 laginous vault simultaneously.16 In 2 separate studies, alterations subsequent to upper jaw surgery would 303
248 Drumheller17 and Huizing18 reviewed and modified be limited and controlled (Fig 3). 304
249 the initial PDO technique. They enabled the nasal pyr- In this technique, by modification of the anterior 305
250 amid to move downward freely by incorporating segment of the circumvestibular incision to a V-shaped 306
251 osseous wedge resection from the frontal ascending full-thickness incision, some muscle attachments 307
252 processes of the maxillary bones. This novel above the osteotomy line will remain intact, making 308
253 approach, inspired by the PDO technique, is known the outcome more predictable. Prevention of the full 309
254 as the let-down operation (LDO) technique (Figs 1, 2). detachment of the muscular insertions of the perirhi- 310
255 nal muscles, not only preserves the underlying soft tis- 311
256 Surgical Technique sue of the aperture piriformis, but also lessens nasal 312
257 base widening. By avoiding undermining of the 313
258 In the present technical note, we have reviewed the 314
259 use of concomitant rhinoplasty and Le Fort I surgery 315
260 with a modified dorsal preservation technique in the 316
261 clinical practice of an oral and maxillofacial surgeon 317
262 in a private hospital. Before the procedure, the surgi- 318
263 cal steps, risks, potential complications, and benefits 319
264 of the technique were described in detail to each pa- 320
265 tient, and all the candidates for the surgery provided 321
266 written informed consent. The procedures were per- 322
267 formed in 4 steps: 1) Le Fort I osteotomy and down- 323
268 fracture; 2) intraoral septoplasty; 3) nasal vault 324
269 osteotomy; and 4) open or closed tip-plasty, suturing, 325
270 and splinting. 326
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272 STEP 1: UPPER JAW SURGERY 328
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273 The surgery was performed with the patient under 329
274 general anesthesia. After nasal intubation and local 330
275 anesthesia administration (2% lidocaine with epineph- 331
276 rine at a concentration of 1:80,000), the overlying soft 332
277 tissue was elevated using a conventional maxillary FIGURE 4. Correction of nasal tip droop using the posterior strut
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278 vestibular incision. After subperiosteal dissection, method. 334
279 the osteotomy design could be considered. The Keyhan et al. Dorsal Preservation Rhinoplasty and Orthognathic 335
280 preferred osteotomy design in such cases is a modified Surgery. J Oral Maxillofac Surg 2020. 336

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356 FIGURE 5. Modified dorsal preservation rhinoplasty using intraoral access. 412
357 Keyhan et al. Dorsal Preservation Rhinoplasty and Orthognathic Surgery. J Oral Maxillofac Surg 2020.
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360 anterior mucoperiosteal flap, a direct ostectomy of the directly related to the favorable shape, form, and 416
361 aperture piriformis base, comprising the anterior nasal height of the dorsum. In our experience, the average 417
362 spine, was performed. The lateral and posterior stan- amount of nasal pyramid inferior movement will rarely 418
363 dard Le Fort I osteotomy was continued to prevent be more than 5 mm. 419
364 detachment of the harvested anterior osteo- Because access to the nasal septum is limited when 420
365 musculomucosal flap from the nasal septum. This approaching through a Le Fort downfracture, which 421
366 technique preserved the natural insertions of the makes modification of the septum difficult, some sur- 422
367 depressor alae, transverse nasalis, and depressor septal geons have found it less complex to perform the septal 423
368 muscles of the nasolabial region.19,20 After perfor- modification via an intranasal approach. However, we 424
369 mance of the lateral maxillary osteotomies, lateral just removed the inferior strip through the intraoral 425
370 nasal wall osteotomies, subnasal osteotomy, septal os- approach. Also, we could resect the septum caudal 426
371 teotomy, and bilateral pterygoid plate osteotomy, the area through the intraoral approach. Therefore, the 427
372 downfracture maneuver provided intraoral access to choice of an intranasal or intraoral approach to pro- 428
373 the nasal cavity and septum. vide access depends on surgeon preference. 429
374 For cases of nasal tip droop, the nose tip should be 430
375 rotated upward by removal of the caudal edge of the 431
376 STEP 2: INTRAORAL SEPTOPLASTY septum or application of the posterior strut technique 432
377 In step 2, because it was possible for the presence of introduced by Çakır.21 Using the posterior strut 433
378 the tube to disrupt the ability of the surgeon to manage method, to preserve the Pitanguy midline ligament 434
379 the tissues in the area, the mucosa was dissected as and to avoid any potential disruption or destruction, 435
380 much as possible on each side, upward and backward, a V-shaped wedge should be removed immediately 436
381 to the vomer bone bilaterally to expose the inferior behind the caudal septal edge of the cartilage through 437
382 border of the osseous and cartilaginous septum and the intraoral approach. This will result in an approxi- 438
383 resect the inferior septal strip. To provide complete ac- mation of the septal edges by suturing, which can 439
384 cess to the septum, subperichondrial and subperios- effectively adjust the nasal tip rotation (Fig 4). 440
385 teal dissection of the cartilage and a part of the In most cases, the inferior septal strip will be 441
386 vomer bone was required. To resolve hump excess competent for columellar strut or alar rim grafts. 442
387 and determine the amount of inferior movement of Once inferior septal strip removal has been 443
388 the nasal pyramid, the dimensions for inferior septal completed, preserving the cartilaginous L-shaped strut 444
389 strip removal were measured during the preoperative septum, additional cartilage can be harvested from the 445
390 examinations. Because inferior septal strip resection cartilaginous body. After intraoral septoplasty, the 446
391 will determine the amount of septum that remains, septal mucosal layers should be sutured. Maxillary fix- 447
392 the size and shape of the resection are important and ation was performed a little lateral to the pyriform 448

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487 FIGURE 6. Intraoperative views of a sample case showing application of conventional Le Fort I osteotomy. Modified subnasal osteotomy is a 543
recommended optional technique that can be used after increased surgeon experience in concomitant surgery. The schematic view in Fig 4
488 describes the modified subnasal osteotomy. 544
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Keyhan et al. Dorsal Preservation Rhinoplasty and Orthognathic Surgery. J Oral Maxillofac Surg 2020.
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492 edge using the 4-hole L-plate. Because of the possible Before nasal skeletonization, the local anesthetic 548
493 limitations, suturing of the vestibular incision should agent (2% lidocaine and epinephrine at a concentra- 549
494 be postponed to the end of the surgery. tion of 1:80,000) was injected adjacent to the nasal 550
495 anatomic area to achieve hemostasis and hydrodissec- 551
496 tion. The use of an open or closed approach depends 552
497 STEP 3: NASAL VAULT OSTEOTOMY on the patient’s problem being treated and surgeon 553
498 After maxillary fixation in its modified position, the preference. Accordingly, the closed approach could 554
499 nasotracheal tube was removed, and orotracheal intu- also be used with this technique. After the transcolu- 555
500 bation was performed. To facilitate the process and mellar open approach and mucosal incisions, subper- 556
501 prevent the difficulties associated with changes in ichondrial and subperiosteal dissection was 557
502 the intubation technique during surgery, submental extended to the radix area. After complete dissection, 558
503 intubation could be used from the beginning as an the surgeon performed bilateral transverse nasal os- 559
504 alternative. teotomy, intraoral lateral nasal osteotomies, and 560

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580 FIGURE 7. Patient profile view at the termination of the operation.
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Keyhan et al. Dorsal Preservation Rhinoplasty and Orthognathic
582 Surgery. J Oral Maxillofac Surg 2020. 638
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vertical septal osteotomy to mobilize the nasal pyra-
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mid as a unit. Transverse osteotomies were applied
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transcutaneously from the radix to the level of the
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medial canthus on both sides.
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Internal lateral nasal osteotomies were performed
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bilaterally using an intraoral approach with preserva-
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tion of the Webster triangles. When the ‘‘push-down’’
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technique was indicated, to perform an internal lateral
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nasal osteotomy, the lateral nasal curve osteotome was
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used from the caudal portion of the pyriform aperture
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to the medial canthus in an upward direction on each
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side to connect with transverse osteotomies bilaterally.
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When the ‘‘let-down’’ technique was considered, it was
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implemented by bilateral osseous wedge resection
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from the frontal ascending processes of the maxillary
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bones, with the aid of piezoelectric surgery (Video 1).
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Finally, to mobilize the nasal vault as an integrated
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single unit, we performed a vertical septal osteotomy
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via a skin stab incision several millimeters more ce-
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phalic than the keystone area downwardly and anteri-
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604 660
orly. To prevent cerebrospinal fluid leakage, caution
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was exercised to prevent any direction and movement
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of the osteotome posteriorly (Video 2).
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Preservation of the dorsal shape is extremely diffi-
608 664
cult when the keystone area cannot be modified auto- FIGURE 8. Left, Preoperative and Right, postoperative views of a
609 665
matically owing to asymmetry, depression, or scarring. sample case.
610 666
Therefore, this technique is indicated only for straight- Keyhan et al. Dorsal Preservation Rhinoplasty and Orthognathic
611 Surgery. J Oral Maxillofac Surg 2020. 667
forward and mild dorsal hump cases (Figs 5, 6).
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613 669
614 STEP 4: TIP-PLASTY, SUTURING, AND SPLINTING surgery involving the tip of the nose, dorsal modifica- 670
615 Finally, after the determination of the modified nasal tions should always be the first step before tip refine- 671
616 vault position, tip-plasty can be considered. In any ment, because dorsal lowering can significantly 672

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673 Results 729

674 730
675 A total of 48 patients (23 females and 15 males) had 731
676 undergone concomitant rhinoplasty and Le Fort I sur- 732
677 gery using a modified dorsal preservation technique. 733
678 The patients were followed up for 1 year. No patient 734
679 reported dissatisfaction with the results of surgery 735
680 regarding the nasal and facial esthetics. No evidence 736
681 of severe complications, such as saddle nose, severe 737
682 deviation, airway compromise, or severe asymmetry, 738
683 was observed postoperatively (Figs 8 to 11). 739
684 740
685 741
Discussion
686 742
687 The main differences between our method and the 743
688 conventional technique are the intraoral access for 744
689 septoplasty and lateral nasal osteotomy in both PDO 745
690 and LDO techniques, the area of septal strip removal, 746
691 and, most importantly, the possibility of concomitant 747
692 surgery. For cases of upper jaw surgery, if one intends 748
693 to perform superior septal strip removal using the con- 749
694 ventional dorsal preservation technique, a flail septum 750
695 will be encountered without any articulation, not only 751
696 inferiorly, but also superiorly and posteriorly owing to 752
697 the disarticulation of the septum and the role of the 753
698 maxillary crest. 754
699 According to recent research by Daniel,22 almost al- 755
700 ways, a true hump will be a cartilaginous hump, not a 756
701 bony hump. Using this technique, after osteotomy and 757
702 displacement of the nasal pyramid, rasping can be 758
703 used to smooth the surfaces and edges without the cre- 759
704 ation of an open roof. In our first experience using this 760
705 surgical technique, the determination of the amount of 761
706 the inferior strip to be removed for adjustment of the 762
707 dorsum position was time-consuming and had to be 763
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708 performed gradually to achieve an appropriate posi- 764

709 tion. However, in further cases and with increasing 765
710 experience, the duration of this step was significantly 766
711 reduced. No limitation exists regarding the amount of 767
712 FIGURE 9. Left, Preoperative and Right, postoperative views of a
inferior pyramid movement. However, it should be 768
713 sample case. calculated in the preoperative evaluations. In addition, 769
714 Keyhan et al. Dorsal Preservation Rhinoplasty and Orthognathic one can use the PDO on 1 side and the LDO on the 770
715 Surgery. J Oral Maxillofac Surg 2020. other side, even in the deviated nose. However, this 771
716 is not recommended for cases of concomitant rhino- 772
717 plasty and orthognathic surgery. 773
718 change the extrinsic characteristics of the tip. Conven- Simultaneous implementation of maxillary orthog- 774
719 tional suturing and nasal splinting were performed. nathic surgery and rhinoplasty, specifically the applica- 775
720 The application of a nasal pack should be avoided tion of our modified dorsal preservation technique, 776
721 (Fig 7, Video 3). Also, it is preferable to avoid intermax- will minimize morbidity and the incidence of postop- 777
722 illary fixation because of the temporary compromising erative complications. Using this technique, not only 778
723 effects of rhinoplasty on normal airway function. the duration of anesthesia can be minimized, but also 779
724 Compared with the time required for upper jaw sur- conservative dissection, preservation of the keystone 780
725 gery and rhinoplasty independently, the total opera- area, and subsequent elimination of further require- 781
726 tive time required for simultaneous upper jaw ments for reconstruction will be achieved. The main 782
727 surgery and rhinoplasty in our experience has been reason that reduces the operative time in our tech- 783
728 less than 4 to 5 hours. nique and considered one of its main advantages is 784

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812 FIGURE 10. Left, Preoperative and Right, postoperative views of a sample case. 868
813 Keyhan et al. Dorsal Preservation Rhinoplasty and Orthognathic Surgery. J Oral Maxillofac Surg 2020. 869
814 870
815 871
816 the lack of the need for any profound or extensive overlooked. The next key point is to detect the effect 872
817 septal surgery. Additional advantages of this technique of the jaw movements on the soft tissues to predict the 873
818 compared with performing jaw surgery and rhino- subtle changes to the nose. 874
819 plasty separately include the reduced overall recovery No limitations exist regarding the amount of 875
820 time, reduced patient expense, the reduced risk and nasal bone reduction in this technique. Lateral 876
821 possible complications of anesthesia, and increased nasal bone strips can simply be removed in LDO, 877
822 patient satisfaction. In addition, this technique does and lateral nasal osteotomy can be performed 878
823 not violate other techniques at all; it is just an optional regarding PDO. However, owing to the potential 879
824 alternative. complications regarding concomitant surgery, we 880
825 After the preoperative evaluations, if the surgeon believe this technique should be limited to simple 881
826 decides to perform concomitant surgery, the surgeon cases only. 882
827 should be prepared to manage the complications and Bone removal from the lateral nasal walls and septal 883
828 unexpected events associated with the technique, inferior strip removal should be performed after a 884
829 which were described in our introduction. Care comprehensive careful analysis. In addition, the bone 885
830 must be taken to prevent damage to the nasal airway and cartilage can be removed gradually to prevent sad- 886
831 during the intraoral septoplasty. In some cases, sub- dle nose deformity during the procedure. However, in 887
832 mental intubation could be considered. If the total our experience, no patient had developed saddle 888
833 operative duration is 4 hours or less and the bleeding nose deformity. 889
834 has been minimal, jaw surgery and rhinoplasty can Considering the residual hump as the most signif- 890
835 be performed simultaneously. The amount of nasal icant complication regarding nasal surgery, studies 891
836 and regular maxillary bleeding should not be greater have indicated that the percentage of residual 892
837 than 100 mL. Once the bleeding and operative time humps in cases of concomitant rhinoplasty and or- 893
838 can be controlled, the surgeon can consider concomi- thognathic surgery has not been significantly greater 894
839 tant surgery. The use of a tumescent solution and than that after the performance of separate rhino- 895
840 blood pressure control are issues that should not be plasty and orthognathic surgery.3 However, in the 896

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933 FIGURE 11. Comparison of preoperative and postoperative occlusion of a sample case. 989
934 Keyhan et al. Dorsal Preservation Rhinoplasty and Orthognathic Surgery. J Oral Maxillofac Surg 2020. 990
935 991
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937 case of dorsal bony hump removal, the use of the The use of a dorsal preservation technique can occa- 993
938 dorsal preservation technique has generally sionally result in complications, such as hump recur- 994
939 been rejected. rence and lateralization of the nasal pyramid.26-29 995
940 The precise detection of any deviation or asymme- One practical solution to prevent such complications 996
941 try before surgery is of utmost importance in the selec- is to fix and stabilize the dorsum in the new 997
942 tion of the osteotomy and septoplasty method.23 An position. The dorsal preservation technique should 998
943 accurate analysis of the nostrils should be performed be confined to primary reduction rhinoplasty. Thus, 999
944 in terms of 3 fundamental characteristics: size, orienta- ‘‘cartilaginous’’ noses are privileged indications for 1000
945 tion, and esthetic landmarks.24 In addition, an exami- maintaining the keystone area using the dorsal 1001
946 nation of the septum and nasal cavity using a flexible preservation technique, because it will prevent 1002
947 endoscope can be performed to assess for septal devi- upper lateral cartilage collapse after dorsal resection. 1003
948 ation or deflection.25 In addition, turbinate abnormal- Concerning the dorsal preservation technique, the 1004
949 ities and concha bullosa must be diagnosed greater the cartilaginous segment, the greater the 1005
950 preoperatively, because these problems must be cor- indications for this technique. The clinically 1006
951 rected in the first stage of septorhinoplasty. significant point about dorsal preservation 1007
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1009 techniques is that, in most cases, no spreader grafts 4. Waite PD, Matukas VJ, Sarver DM: Simultaneous rhinoplasty pro- 1065
cedures in orthognathic surgery. Int J Oral Maxillofac Surg 17:
1010 will be required. 1066
298, 1988
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