Management of the Keel Nose and Associated Valve Collapse

Objectives  To analyze the anatomical abnormality of the keel nose and correlate the findings with etiologic maneuvers of a routine rhinoplasty procedure; to identify the contributing factors and offer suggestions to avoid or decrease the severity of these surgical complications; and to present an effective revisional procedure to correct the functional and cosmetic consequences of this deformity.

Patients and Methods  A total of 47 patients (31 women and 16 men; age range, 18-71 years) with a keel-appearing nose presented for revision rhinoplasty. All had undergone at least 1 rhinoplasty procedure, and 39 had undergone 2 or more previous nasal procedures. All patients had bilateral lateral nasal wall collapse and an associated severely compromised internal nasal valve. All patients underwent reconstruction with a conchal cartilage overlay graft.

Results  All patients had a moderate to excellent cosmetic improvement; the subjective improvement in nasal airway was more dramatic. Since patients with a keel nose have an associated internal valve collapse, both abnormalities are addressed simultaneously with the conchal cartilage overlay repair, which results in minimal morbidity with no major complications.

Conclusions  Conchal cartilage overlay repair uses a cartilage graft from the auricle with a recommended external rhinoplasty for placement. Appropriate sizing and fashioning precede the precise placement and suture fixation. This technique addresses both functional and cosmetic abnormalities.

THERE IS A STRONG likelihood that a procedure as complicated as a rhinoplasty will result in some unintended consequences.^1-3 To achieve the desired goals in rhinoplasty, there is usually an elaborate sequence of incisions, excisions, and version techniques, with deliberate and sometimes unintended consequences, which promote the art of defensive surgery. Perhaps the greatest stride in defensive surgical treatment is the generally accepted tenet of tissue preservation as opposed to the once common practice of more radical tissue resection in rhinoplasty. Realizing and optimizing the goals of surgery as well as eliminating or minimizing the unintended outcomes should be the focus of all surgeons who are engaged in rhinoplasty surgery. This article addresses an aspect of this philosophy.

Surgeons have retrospectively evaluated their long-term rhinoplasty outcomes only over the past 1 or 2 decades. This follow-up has allowed scrutiny of the consequences of surgical actions. In the 1970s, it was routine to present 6- to 12-month postoperative results with a rather smug self-assurance of success. It is our experience, however, that time itself is the real enemy of the rhinoplasty surgeon. With the exception of some cases of cleft lip rhinoplasty, where the skin memory of the deformity gradually diminishes, the passage of time amplifies surgical imperfections in patients who have undergone rhinoplasty. This is certainly true in cases involving keel nose or midnasal collapse.

The preoperative photos of all patients who underwent a secondary rhinoplasty procedure performed by the senior author (F.J.S.) since 1982 were reviewed, and 47 were categorized as demonstrating a keel nose deformity. We define keel nose as an extremely narrow nose with an inordinately acute angle of the upper lateral cartilages as they meet the quadrangular septum. This keel defect often extends cephalically and includes the bony pyramid. As time passes, the upper lateral cartilages drift inferiorly as a result of their resection from the septum. This deformity is more likely caused, or at least compounded, by severing of endonasal mucosa. As the upper lateral leafs retract inferiorly, the septum often appears in relief as a keel (Figure 1). A profound functional inspiratory collapse of the flail lateral sidewalls occurs in association with keel nose deformities. Therefore, the correction must address both the functional collapse and the keel nose cosmetic deformity.

Our series included 47 patients (31 women and 16 men; age range, 18-71 years). Conchal cartilage overlay grafts were used to correct the keel nose deformity in all cases.

We routinely use the external approach, but on occasion we have used an endonasal technique. The latter is actually more time consuming because of the difficulty in accurate graft placement in the absence of direct visualization. The conchal cartilage graft can be harvested from either ear. The skin flap is elevated, with an incision just medial to the crus of the antihelix. The incision is carried out anteriorly medial to the inferior crus and inferiorly to the roll of the antitragus. The skin flap is attached and hinged anteriorly at the external meatus, and the entire conchal cartilage is removed. The skin flap contains the perichondrium; the posterior perichondrium is firmly adherent to the cartilage and stays with the graft. As the patients age, the auricular cartilage calcifies. Care in harvesting is therefore advised with elderly patients. It is quite easy to break and lose the necessary graft continuity if one is not careful. The concha is first shaped with a knife (Figure 2) and further contoured with a diamond fraise. The cartilage is abraded on the surface, which is devoid of attached perichondrium. The graft is sized by placing it over the midnasal deformity. It is designed to replace the supraseptal integrity of the upper lateral cartilages, which have lost their lateral support. The graft must be positioned cephalic to the lower lateral cartilage (Figure 3). On occasion, resected lower lateral cartilages must be reconstructed, which can be done with septal or additional auricular cartilage. Once the graft is appropriately fashioned and sized, the septum is resected as necessary to the desired level. At this point, we usually place a fixation suture to stabilize the graft. The external rhinoplasty skin flap is repositioned, and 1 to 2 percutaneous mattress sutures are placed on each side of the nose to ensure proper stabilization and to coapt the skin and endonasal lining to the graft and upper lateral cartilage remnant. The mattress sutures prevent blood and/or fluid accumulation, which could slow healing, cause an infection, decrease assimilation of the graft, result in thickened lateral walls, or perhaps even cause resorption of the graft.

The first and most important mattress suture is oriented vertically inside the nose and horizontally outside the nose. The vertical orientation snugs the endonasal lining into the apex of the valve, hopefully recreating a properly functioning nasal valve. The cutaneous part of the mattress sutures is oriented horizontally or parallel to the relaxed skin tension lines for cosmetic considerations. The sutures are tied over a Freer elevator and thus are loose enough to accommodate the expected tissue swelling. There is no intranasal packing or dressing. A routine external dressing of paper tape and plaster casting material is used. The cast is removed in 5 days, and the mattress sutures are removed 1 week later. Very rarely, swelling may be excessive and the sutures can burrow into the skin, necessitating early removal of the sutures. This complication occurred in 2 of the cases in our series.

All of our patients benefited, to varying degrees, both cosmetically and functionally. There was subjective improvement in nasal breathing in all patients. One patient required dermabrasion at the mattress suture sites, where swelling had buried the suture in the skin. There was a good deal of inflammation when the sutures were removed prematurely on day 5.

Because we did not identify any patients with the keel nose deformity who did not have collapse in the valve area, the correction must address both concerns. Keel deformities are only one of the situations in which valve abnormalities occur.

A few patients do not consider the excessively narrow nose a cosmetic problem. Intrinsic to our recommended correction is a postoperatively broader nose. Although the patients may have preferred the narrower nose, the improved nasal function has resulted in satisfaction in all cases. Two patients in this study required a second procedure for what we consider a less-than-precise technical execution. In both cases, there was a failure to size the lateral extent of the graft, which caused a slight bowing. This complication could have been avoided by trimming the graft or developing a more adequate superolateral pocket.

It is clear that the keel nose deformity with lateral wall collapse is the consequence of surgery, and it is equally clear that the functional component is aggravated by time and aging. There are numerous approaches to correcting valve problems,^4-7 but in our experience they fail to improve both the functional and the cosmetic keel nose abnormality. The popular use of spreader grafts,^8,9 which may improve the narrow appearance, has little long-term effect on improving nasal function other than minor valve problems. Correcting the cosmetic keel nose abnormality without addressing the functional valve collapse fails to provide optimum treatment. Our recommended correction of the nasal airway difficulty has the added benefit of addressing the keel nose cosmetic deformity.

The most common and consistent predisposing factors in a majority of the cases in our series are previous rhinoplasty procedures (2 or more), significant hump removal at the first procedure, relatively short bony-to-cartilage ratio in the nasal vault, periosteal tunnels developed prior to lateral osteotomies, and severing of endonasal mucosa with resection of the upper lateral cartilages from the septum. Another predisposing condition occurs when the primary procedure is performed endonasally (Figure 4). Our recommended method of correction uses a properly sized conchal cartilage graft placed between the remaining cartilaginous midnasal structural vault and the elevated skin flap.¹⁰ This properly shaped and fashioned conchal cartilage graft is remarkably like an intact bilateral upper lateral cartilage (Figure 5). The septal cartilage, which is the keel portion of the deformity, must often be brought down to accommodate the increased height of the dorsum, which is caused by the conchal graft. This correction results in a more appropriately shaped nose.

The integrity of the lateral support of the upper lateral cartilage is essential to create a valve angle that is sufficient for a normal airway. Severing the upper laterals from the cartilaginous septum often destroys the rigid integrity required to maintain a valve angle that is sufficient for a patent nasal airway. Spreader grafts lateralize the upper lateral cartilage 2 to 3 mm (the width of the graft placed), but do little to change the flaccidity of the lateral nasal wall. Inspiration creates a relative vacuum intranasally, which continues to collapse the nasal wall, in spite of the 2- to 3-mm lateralization of the upper lateral cartilage. Our experience with spreader grafts is that minor to moderate keel nose deformities can be improved markedly in appearance but that any significant airway improvement is rather rare. The flail lateral nasal walls are not significantly changed functionally with a cartilage shim at the angle. It is our contention that to consistently reconstruct the valve angle and support the upper lateral cartilage, structural support is required over the septum. To address both the functional flail lateral nasal sidewalls and the inordinately narrow (keel) nose, we recommend the placement of a conchal cartilage overlay graft (Figure 6 and Figure 7).

To repair the keel nose deformity, conchal cartilage is harvested and fashioned so that it mimics the intact upper lateral cartilages. Our recommended surgical intent is to recreate the integrity of the preoperative anatomy.

The cartilage is shaped first with a No. 15 blade and completed with a diamond fraise wheel abrasion. This procedure permits the perichondrium attached to the posterior aspect of the graft to remain intact, thus optimizing the rapid assimilation of the cartilage graft. By thinning the periphery of the graft, the likelihood of a visible or palpable ridge is greatly minimized.

Reconstructing the graft is an important step, as it recreates the upper lateral cartilage. It must be placed cephalic to the lower lateral cartilage. We use 2 to 4 percutaneous mattress sutures not only to firmly fix the graft in place, but also to coapt the tissues. This precludes a lamina of blood accumulation above the graft, which could lead to resorption of the cartilage or thickening of the lateral nasal wall. These sutures are routinely removed approximately 10 days after surgery. The technique described herein is effective in correcting the 2 major problems of cosmetic and airway obstruction. We have used this technique in 47 patients, with excellent results.

Accepted for publication December 17, 2001.

Corresponding author and reprints: Fred J. Stucker, MD, Department of Otolaryngology–Head and Neck Surgery, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Room 33932, Shreveport, LA 71103-4209.