COSMETIC

Orthognathic Surgery and Rhinoplasty:

Simultaneous or Staged?
Alexander H. Sun, B.S.
Background: Orthognathic surgery can significantly impact the nasolabial en-
Derek M. Steinbacher,
velope, and at times requires an adjunctive rhinoplasty. The purpose of this
D.M.D., M.D.
study was to evaluate nasal morphology in orthognathic patients, focusing on
New Haven, Conn. predictive variables, and the need for and timing of definitive rhinoplasty.
Based on these data, an algorithm for the implementation of adjunctive rhi-
noplasty is proposed.
Methods: A review of cases over a 3-year period was completed. Information
regarding demographic, diagnostic, and operative details; nasal morphology;
and use of rhinoplasty was compiled. Three-dimensional images were used to
quantify anatomical variables.
Results: Over 589 patients were reviewed during this period. Of these, 163
fulfilled inclusion criteria for this study. The mean age was 23.3 years. In total,
41.7 percent of orthognathic cases underwent adjunctive rhinoplasty. Of these,
82.4 percent were staged and 17.6 percent were simultaneous. The average
time between staged procedures was 208 days. When simultaneous, 16.7 per-
cent of the orthognathic procedures had significant maxillary movement (ad-
vancement >4 to 5 mm, impaction >2 mm, alar base excisions); in comparison,
92.9 percent of staged cases had significant maxillary movement (p < 0.0001).
All patients had self-reported satisfaction with functional and aesthetic results
during the follow-up period.
Conclusions: Nasal and jaw deformities are intricately interlinked. In this series,
the authors identified patterns requiring adjunctive rhinoplasty in the setting
of orthognathic surgery. The authors present an algorithm to extensively treat
the nasomaxillofacial relationship using orthognathic surgery alone, orthogna-
thic surgery in concert with rhinoplasty, or orthognathic surgery followed by
staged rhinoplasty. (Plast. Reconstr. Surg. 141: 322, 2018.)

O
rthognathic surgery is a powerful tool to also impact the nasal base.3 We previously charac-
improve facial aesthetics and function. terized Le Fort–induced nasolabial changes using
When performed well, the altered bony three-dimensional photogrammetry.4–7 These
position has a positive impact on the facial soft- changes can either improve or worsen the postor-
tissue structure and support. However, certain thognathic nasal appearance, depending on the
untoward effects may at times be encountered. In preexisting nasal morphology.
particular, the Le Fort I osteotomy can alter the The most favorable scenario is when the nasal
nose and can result in base widening, tip changes, appearance is improved following Le Fort oste-
reduced nasofrontal angle, and shortened nasal otomy. However, a postoperative nasal deformity
length.1,2 These changes are caused primarily by can occur when (1) an intrinsic deformity fails
changes in the skeletal support, which impacts the to improve (or worsens) after a Le Fort I proce-
overlying nasal tissues and vault.3 Subperiosteal dure; or (2) a well-balanced nose is altered, and
dissection and wide surgical exposure and release deformed, because of the impact of orthognathic
surgery. Measures are taken to avoid this latter sce-
From the Section of Plastic and Reconstructive Surgery, Yale nario, but some degree of deformity may be cre-
School of Medicine. ated regardless of mitigation attempts.
Received for publication April 26, 2017; accepted August
31, 2017.
Presented in part at the Rhinoplasty Society 20th Annual Disclosure: The authors have no financial interest
Meeting, in Montreal, Quebec, Canada, May 14, 2015. to declare in relation to the content of this article.
Copyright © 2018 by the American Society of Plastic Surgeons There were no sources of funding.
DOI: 10.1097/PRS.0000000000004020

322 www.PRSJournal.com
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 Volume 141, Number 2 • Orthognathic Surgery and Rhinoplasty

In these settings, the nasal deformity is best Table 1. Number of Orthognathic Procedures with
addressed using definitive rhinoplasty. Tempo- and without Adjunctive Rhinoplasty
rally, the rhinoplasty can be performed concurrent All No Adjunctive Simultaneous Staged
with jaw surgery, or in a delayed/staged fashion.8,9 ­Orthognathic Rhinoplasty Rhinoplasty R
­ hinoplasty
The purpose of this study was to evaluate nasal 163 95 12 56
deformity in the setting of orthognathic surgery,
characterize predictive variables, and describe an
algorithm for timing and management.8 Empha- performed simultaneously and the other 82.4 per-
sis is placed on (1) predicting the need for rhi- cent underwent procedures performed in a staged
noplasty and (2) analyzing the management and fashion. The average time between staged proce-
outcomes of a large cohort of patients. dures was 208 days. In the patients who underwent
Le Fort I osteotomy and required rhinoplasty,
few procedures were performed simultaneously
PATIENTS AND METHODS (3.7 percent), compared with the 96.3 percent
This is an institutional review board–approved that were performed in a staged fashion. In com-
retrospective review of orthognathic subjects parison, all patients who underwent genioplasty
treated over a 3-year period by the senior author who needed adjunctive rhinoplasty had the pro-
(D.M.S.). Patients were excluded for lack of fol- cedures performed simultaneously. For patients
low-up (<1.5 years) or incomplete documentation. who underwent a combination of genioplasty and
Demographic, diagnostic, and operative details Le Fort I osteotomy and/or bilateral sagittal split
were compiled. Presence or absence and timing osteotomy, 90.7 percent underwent a staged pro-
of rhinoplasty was also recorded. Groups were cedure when adjunctive rhinoplasty was necessary.
then subdivided into the following: (1) orthogna- Of simultaneous procedures performed, 75.0 per-
thic procedure and simultaneous rhinoplasty, (2) cent were in patients who underwent genioplasty
orthognathic procedure and staged rhinoplasty, with bilateral sagittal split osteotomy alone with
and (3) orthognathic procedure alone where the no maxillary movements.
nose was aesthetic postoperatively. Three-dimen- Of all patients, when the orthognathic proce-
sional photographs were assessed at standardized dure and the rhinoplasty were performed simul-
time points using the Vectra 3D Imaging system taneously, only 16.7 percent of the orthognathic
(Canfield Scientific, Parsippany, N.J.). Diagnos- procedures had significant maxillary movement;
tic, morphologic, and treatment variables were this is in comparison to the staged rhinoplasty
stratified as an algorithmic approach. Statistics group, where 92.9 percent of patients had sig-
were performed in IBM SPSS Version 23 (IBM nificant maxillary movement (p < 0.0001). For
Corp., Armonk, N.Y.). Tests were two-tailed, with orthognathic surgery involving the maxilla, a
an alpha of 0.05. simultaneous rhinoplasty was typically performed
only in situations of minimal advancement (<4 to
RESULTS 5 mm), minimal impaction (<2 mm), and in the
During this period, 362 rhinoplasties and absence of alar base excisions. Of the 82.4 percent
227 orthognathic procedures were performed. of rhinoplasty patients who underwent staged
Of these, 262 rhinoplasty and 163 orthognathic procedures, the most common reasons were if
patients fulfilled criteria of having 1.5 years of the maxilla was involved and large movements
follow-up (Table 1). The mean age was found to or rotations were introduced by the orthognathic
be 23.3 years, and 65.6 percent of patients were surgery, if the deformity was directly attributable
female patients. In total, 68 patients underwent to the Le Fort osteotomy, or if there was intrin-
both orthognathic surgery and rhinoplasty in sic nasal deformity. During the 1.5-year follow-up
either a simultaneous or a staged fashion. Of the period, no patients required a revision procedure,
95 patients who had no rhinoplasty, there was and all patients self-reported being satisfied with
no intrinsic deformity, and orthognathic surgery their functional and aesthetic results.
either did not change the nose appreciably or
improved the nasal form. These changes included DISCUSSION
an improved dorsal hump, forward projection of
the nasal tip, improved supratip break, wider alar Orthognathic Surgery and the Nasolabial
base, increased nasolabial angle, and wider nos- Envelope
trils. Of the 68 patients who underwent adjunctive Orthognathic surgery can dramatically
rhinoplasty, 17.6 percent underwent procedures alter the nasolabial envelope, and several of

323
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 Plastic and Reconstructive Surgery • February 2018

Fig. 1. Staged rhinoplasty for nasal deformity worsened by orthognathic surgery. Patient is shown preoperatively (left); after
orthognathic surgery (center); and after rhinoplasty (right).

these changes have been well-characterized are predictable to some degree and may be desir-
in previous studies.5–7 These changes include able in patients with intrinsic nasal deformity,
an increase in the nasolabial angle leading to such as a narrow alar base or underrotated nasal
increased tip rotation, an absolute increase (but tip before surgery.3 In fact, over 60 percent of
relative decrease) in nasal tip projection, a wid- patients undergoing orthognathic surgery have
ened alar base, more horizontal nostrils, and been found to have concurrent nasal deformity
reduced columellar height. These alterations before surgery.10

Table 2. Surgery-Induced Deformity and Management

Deformity Cause Maneuvers/Solutions
Underprojected tip Loss of tip support, decrease in projection Tip suturing, columellar strut, CSEG, tip
­grafting
Wide alar base Intrinsic; widening from Le Fort advancement, Increase tip projection, alar base and/or sill
impaction, widening, CCW excisions
Short, wide, flat nostrils Intrinsic, alar base widening in context of loss of Increase tip projection, increase infralobular
tip support height alar base and/or sill excisions
Overrotated tip Increase NL angle with Le Fort advancement Separate UCL from scroll, CSEG, infralobular
tip grafting, dorsal onlay
Excess nostril display Alar retraction, buckled columella, Tongue-in-groove medial crural cephalic
(lateral) overrotated tip ­positioning, derotate tip, lateral crural
­support
Midvault narrowing Intrinsic, perspective against widened alar base Spreader grafts, spreader flaps
Prominent dorsum Intrinsic Dorsal reduction
Flat dorsum Intrinsic, worsened from Le Fort advancement Dorsal augmentation, rib or septal cartilage
Deep supratip break Worsened from Le Fort advancement Tip repositioning, caudal midvault
­augmentation
CSEG, caudal septal extension graft; CCW, counter-clockwise; NL, nasolabial; UCL, upper lateral cartilage.

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 Volume 141, Number 2 • Orthognathic Surgery and Rhinoplasty

Fig. 2. Staged rhinoplasty for intrinsic nasal deformity not corrected by orthognathic surgery. Patient is shown preoperatively
(left); after orthognathic surgery (center); and after rhinoplasty (right).

In other cases, however, the orthognathic proce- was able to improve the nasal deformity. In the rest,
dure itself can induce a nasal deformity (Fig. 1). The orthognathic surgery induced, maintained, or wors-
iatrogenic nasal aberration needs to be anticipated ened the nasal deformity; these were corrected by
and recognized, and will typically require a concur- rhinoplasty, which was conducted in a staged fash-
rent or a staged rhinoplasty to fully correct the nasal ion in a majority of patients.
and facial deformities. In this series of patients, the
most common findings after orthognathic surgery Sequence of Orthognathic Surgery and
included a widened alar base, reduced tip projec- Rhinoplasty
tion, broader tip-defining points, and horizontal If at all possible, our preference is to avoid per-
nares. To target these postsurgical changes, sev- forming rhinoplasty before orthognathic surgery;
eral maneuvers can be performed in an adjunctive instead, rhinoplasty should be a definitive proce-
rhinoplasty (Table 2). In some cases of a wide alar dure to finalize nasal aesthetics and function at the
base, narrowing can be accomplished by increasing time of orthognathic surgery or afterward. This
tip projection alone.11 If the alar base cannot be suf- does not deny, however, that circumstances exist
ficiently narrowed by altering tip projection, sill or in which rhinoplasty may be required for severe
alar wedge excisions can be performed in addition nasal symptoms or morphology, such as in cleft
to increasing the tip projection.12 patients, trauma, and airway obstruction. In such
Finally, there can be the persistence of intrinsic cases, the rhinoplasty may be required before an
nasal deformities after orthognathic surgery (Figs. 2 orthognathic procedure can be performed. These
and 3). This would then include nasal changes from patients were all excluded from this study.
surgery along with any intrinsic deviation, curva- Sometimes, a rhinoplasty can be performed first
ture, septal deviation, asymmetry, constriction, or if the planned orthognathic procedure does not
collapse. In this series, 58.3 percent of patients did involve maxillary repositioning (no Le Fort I oste-
not require rhinoplasty, or the orthognathic surgery otomy or bilateral sagittal split osteotomy and/or

325
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 Plastic and Reconstructive Surgery • February 2018

Fig. 3. Staged rhinoplasty for intrinsic nasal deformity not corrected by orthognathic surgery. Patient is shown preoperatively
(left); after orthognathic surgery (center); and after rhinoplasty (right).

genioplasty only). In this series, one patient under- studied in a large cohort of patients. Several fac-
went a rhinoplasty several months before genioplasty, tors should be considered, including a risk-to-ben-
but this was an exception; no Le Fort I osteotomy efit ratio, when deciding between a simultaneous
was performed to alter the nasomaxillary envelope. or a staged rhinoplasty (Table 3). A simultaneous
Only a minority of our orthognathic patients under- procedure allows for all components of the naso-
went mandibular and chin surgery only. maxillofacial tissues to be manipulated in concert
In addition, there are situations where orthog- (Fig. 4). This reduces the number of procedures a
nathic patients undergo a rhinoplasty or septoplasty patient has to undergo, and may be associated with
performed by a provider who did not recognize the higher patient satisfaction.10,13 Technically, a simul-
dentofacial deformity, or before the dentofacial taneous procedure allows for better hemostasis,
deformity had fully developed. In addition to orthog- visualization, and access during the rhinoplasty.14
nathic surgery, a secondary or repeated rhinoplasty After the orthognathic procedure is complete,
may be necessary in these cases. Such situations fre- the posterior septal angle is secured to the ante-
quently occur when procedures are performed for rior nasal spine. The Le Fort incision can be left
nasal cosmesis or nasal functional deficits without partially open during the open rhinoplasty, which
anticipating present or future need for orthogna- allows for better access to the caudal septum, ante-
thic surgery. When possible, rhinoplasty should be rior nasal spine, inferior turbinates, and piriform
performed concurrently or staged after the orthog- rim.10,14 However, to preserve the nasal mucosal
nathic procedure; if concurrent, rhinoplasty should floor, turbinates are managed endonasally. In addi-
be the second procedure performed. tion, degloving of the maxilla and sidewall dissec-
tion during the orthognathic procedure may allow
Simultaneous versus Staged Rhinoplasty for better hemostasis for the rhinoplasty.
The decision on timing of rhinoplasty in con- A disadvantage of performing a simultaneous
junction with orthognathic surgery has yet to be procedure is the need for a tube exchange from

326
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 Volume 141, Number 2 • Orthognathic Surgery and Rhinoplasty

a nasal endotracheal tube to an oral tube, and disadvantage is that the edema, degloving, and
greater potential for postoperative airway difficul- subperiosteal release during the orthognathic pro-
ties. Postoperatively, we use Doyle splints instead cedure may make the final form unpredictable,
of nasal packing, and guiding elastics instead which can make it difficult to accurately gauge
of wiring for intermaxillary fixation. Another the nasal tip and alar base positions.15 Despite
these disadvantages, the simultaneous approach
does not necessarily result in greater functional
Table 3. Advantages and Disadvantages of or aesthetic complication when performed judi-
Simultaneous versus Staged Rhinoplasty ciously.10 For the simultaneous approach, the
Simultaneous rhinoplasty most common rhinoplasty maneuvers performed
 Advantages included tip refinement, increasing tip projection
   Operative visibility
  Single anesthesia event and rotation, septoplasty, midvault widening (with
 Disadvantages spreader or autospreader grafts), and turbinate
   Predictability ablation or resection. Alar base and sill excisions
  Postoperative airway challenges
Staged rhinoplasty are not ideally performed as a part of concurrent
 Advantages rhinoplasty with orthognathic procedures.
   Predictability The staged rhinoplasty, in contrast, is ideal
  Allows for fine-tuning
  No tube change, shorter procedure lengths for significant intrinsic nasal deformities, espe-
 Disadvantages cially for asymmetry or deviation that would
  Requires second procedure largely remain following orthognathic surgery.
  Avoids piriform plate
We favor a staged/interval rhinoplasty as well

Fig. 4. Simultaneous orthognathic surgery and rhinoplasty. Preoperative (left) and postoperative
(right) images.

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 Plastic and Reconstructive Surgery • February 2018

for surgery-induced nasal deformity. Cases with but it does affect the spatial relationship of the nose
specific types and magnitudes of maxillary repo- and the chin.16 Therefore, a rhinoplasty can be
sitioning, such as counterclockwise rotation, performed concurrently with mandibular advance-
impaction, large advancements, or changes in yaw ment with or without genioplasty. In all other situ-
or rotation, may make it more difficult to predict ations, an adjunctive rhinoplasty should be staged.
the final position of the nasal base. A staged rhino-
plasty allows for the soft tissue to stabilize after the
orthognathic procedure and may allow for greater CONCLUSIONS
predictability of rhinoplasty results. For instance, Nasal deformity can occur concurrently with
after a period of healing from orthognathic sur- maxillofacial dysmorphology, or as a consequence
gery, the alar facial crease or alar base points will of orthognathic surgery. There has been a paucity
stabilize in their final positions along the piriform of literature, however, discussing how nasal changes
aperture. This more stable and finalized soft-tissue following orthognathic surgery predict the need
backdrop will provide the reference against which for rhinoplasty, or comparing simultaneous versus
to plan tip projection, position, and alar base staged rhinoplasty in these cohorts. In this series, we
and/or sill-narrowing procedures. In a staged rhi- demonstrated that there is a reproducible pattern of
noplasty, any maneuver may be used to alter the patient abnormalities that can be comprehensively
tip, midvault, base, dorsum, or septum. Common addressed, and that there are specific situations for the
maneuvers performed during a staged rhinoplasty use of adjunctive rhinoplasty in either a simultaneous
include introducing spreader grafts, increasing or a staged fashion that can best leverage the advan-
the tip projection and definition, modification of tages of either approach. We present an algorithm to
the alar base and/or sill, and turbinate modifica- extensively treat the nasomaxillofacial relationship
tion (especially following significant impaction) using orthognathic surgery alone, orthognathic sur-
(Table 2). Of the patients in our series who under- gery in concert with rhinoplasty, or orthognathic sur-
went rhinoplasty, 82.4 percent of them underwent gery followed by staged rhinoplasty. Through the use
the rhinoplasty in a staged fashion. of this algorithm, patients have reported satisfaction
in results and no revisions have been necessary in the
An Algorithm for Management first 1.5 years of follow-up. Long-term outcomes have
Given the findings and assessment of nasal yet to be assessed, and future studies will seek to quan-
morphology in this series, we propose the follow- titatively evaluate patient satisfaction and photogram-
ing algorithm for the use of adjunctive rhinoplasty metric outcomes of both approaches.
with orthognathic surgery:
Derek M. Steinbacher, D.M.D., M.D.
Yale Plastic Surgery
1. For no nasal deformity or intrinsic nasal P.O. Box 208062
deformity improved by the orthognathic New Haven, Conn. 06510
procedure: no rhinoplasty needed. [email protected]
2. For nasal deformity created by the orthog-
nathic procedure: staged rhinoplasty.
3. For intrinsic deformity that is maintained or PATIENT CONSENT
worsened by the orthognathic procedure: Patients and parents or guardians provided written
simultaneous or staged rhinoplasty based consent for use of patients’ images.
on the considerations below.

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